Provider Demographics
NPI:1851055123
Name:EDMOND CHILD AND FAMILY COUNSELING, CLARK D EDMOND, LICENSED CLINICAL
Entity Type:Organization
Organization Name:EDMOND CHILD AND FAMILY COUNSELING, CLARK D EDMOND, LICENSED CLINICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:951-775-0032
Mailing Address - Street 1:40960 CALIFORNIA OAKS RD # 220
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5747
Mailing Address - Country:US
Mailing Address - Phone:951-676-5154
Mailing Address - Fax:951-516-1015
Practice Address - Street 1:41690 IVY ST STE B6
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9436
Practice Address - Country:US
Practice Address - Phone:951-676-5154
Practice Address - Fax:951-526-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty