Provider Demographics
NPI:1659029981
Name:CLARK MANE, REBECCA LYNNE (AMFT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:CLARK MANE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 MORRISON ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-5321
Mailing Address - Country:US
Mailing Address - Phone:747-251-8622
Mailing Address - Fax:
Practice Address - Street 1:12240 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3891
Practice Address - Country:US
Practice Address - Phone:818-810-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT130166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist