Provider Demographics
NPI:1972980001
Name:CLARK, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66950 IRONWOOD DR APT 223
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-4401
Mailing Address - Country:US
Mailing Address - Phone:760-848-5125
Mailing Address - Fax:
Practice Address - Street 1:66950 IRONWOOD DR APT 223
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-4401
Practice Address - Country:US
Practice Address - Phone:760-848-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor