Provider Demographics
NPI:1912038589
Name:CLARK, LON THOMAS (MFT)
Entity Type:Individual
Prefix:DR
First Name:LON
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:SHINGLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:96088
Mailing Address - Country:US
Mailing Address - Phone:530-949-6394
Mailing Address - Fax:
Practice Address - Street 1:2400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2832
Practice Address - Country:US
Practice Address - Phone:530-247-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38873106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist