Provider Demographics
NPI:1396061255
Name:CLARK, CAROLYN A (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CALIFORNIA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1411
Mailing Address - Country:US
Mailing Address - Phone:707-944-4581
Mailing Address - Fax:707-944-4590
Practice Address - Street 1:150 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1411
Practice Address - Country:US
Practice Address - Phone:707-944-4581
Practice Address - Fax:707-944-4590
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 154771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical