Provider Demographics
NPI:1669229217
Name:CLARK, SABRINA RENEE
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5044
Mailing Address - Country:US
Mailing Address - Phone:707-989-8889
Mailing Address - Fax:
Practice Address - Street 1:712 UTAH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5044
Practice Address - Country:US
Practice Address - Phone:707-989-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician