Provider Demographics
NPI:1891547766
Name:CLARK, VANESSA KATHLEEN (APCC)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:KATHLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 INDIANA AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4279
Mailing Address - Country:US
Mailing Address - Phone:951-778-0230
Mailing Address - Fax:
Practice Address - Street 1:6840 INDIANA AVE STE 275
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4279
Practice Address - Country:US
Practice Address - Phone:951-778-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15899101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health