Provider Demographics
NPI:1134631260
Name:CLARK, SAMUEL REESE
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:REESE
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20542 TOBERMORY CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5837
Mailing Address - Country:US
Mailing Address - Phone:925-278-8100
Mailing Address - Fax:
Practice Address - Street 1:705 W LA VETA AVE STE 208
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4448
Practice Address - Country:US
Practice Address - Phone:714-532-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)