Provider Demographics
NPI:1851468052
Name:CLARK, KRISTIN ANNE
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:MILLIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4577 PRESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9737
Mailing Address - Country:US
Mailing Address - Phone:760-445-2382
Mailing Address - Fax:
Practice Address - Street 1:290 IOOF AVE.
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020
Practice Address - Country:US
Practice Address - Phone:831-466-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73118101YM0800X
CA29221104100000X
CA778781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41807OtherUNICARE NUMBER