Provider Demographics
NPI:1245353358
Name:CLARK, ELAINE SARAH (BA)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:SARAH
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 TELEGRAPH AVE
Mailing Address - Street 2:1212 N. CALIFORNIA ST.
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-1542
Mailing Address - Country:US
Mailing Address - Phone:209-547-5156
Mailing Address - Fax:
Practice Address - Street 1:2429 TELEGRAPH AVE
Practice Address - Street 2:1212 N. CALIFORNIA ST.
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-1542
Practice Address - Country:US
Practice Address - Phone:209-547-5156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health