Provider Demographics
NPI:1942701776
Name:CLARK, SHARIF (CATC-1 #177290)
Entity Type:Individual
Prefix:
First Name:SHARIF
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:CATC-1 #177290
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1416
Mailing Address - Country:US
Mailing Address - Phone:800-675-6110
Mailing Address - Fax:
Practice Address - Street 1:1002 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1416
Practice Address - Country:US
Practice Address - Phone:800-675-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17729101YA0400X
CA177290101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid