Provider Demographics
NPI:1740689397
Name:CLARK, MARY KATHERINE
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SHADLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RAS
Mailing Address - Street 1:1187 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-9136
Mailing Address - Country:US
Mailing Address - Phone:530-865-1146
Mailing Address - Fax:530-865-6483
Practice Address - Street 1:1187 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-9136
Practice Address - Country:US
Practice Address - Phone:530-865-1146
Practice Address - Fax:530-865-6483
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0710221142101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)