Provider Demographics
NPI:1740514470
Name:CLARK, MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 PARKMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2407
Mailing Address - Country:US
Mailing Address - Phone:408-282-0402
Mailing Address - Fax:408-282-0400
Practice Address - Street 1:27127 CALLE ARROYO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2765
Practice Address - Country:US
Practice Address - Phone:949-661-6753
Practice Address - Fax:949-661-6853
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist