Provider Demographics
NPI:1245453034
Name:CLARK, CRAIG WILLIAM (CRAIG CLARK, MFT)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:WILLIAM
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRAIG CLARK, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N WINCHESTER BLVD
Mailing Address - Street 2:SUITE 264
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6520
Mailing Address - Country:US
Mailing Address - Phone:408-296-5758
Mailing Address - Fax:408-247-3976
Practice Address - Street 1:100 N WINCHESTER BLVD
Practice Address - Street 2:SUITE 264
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6520
Practice Address - Country:US
Practice Address - Phone:408-296-5758
Practice Address - Fax:408-247-3976
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34874106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist