Provider Demographics
NPI:1013145093
Name:CLARK, DEANNA CAROL (MA, MFT)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:CAROL
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 W. ALAMEDA AVE. PMB 208
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2846
Mailing Address - Country:US
Mailing Address - Phone:818-319-1956
Mailing Address - Fax:
Practice Address - Street 1:911 E COLORADO BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1773
Practice Address - Country:US
Practice Address - Phone:818-319-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health