Provider Demographics
NPI:1811230980
Name:CLARK, WALTER OTHA III (CATC II)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:OTHA
Last Name:CLARK
Suffix:III
Gender:M
Credentials:CATC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 PRESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4453
Mailing Address - Country:US
Mailing Address - Phone:951-782-2400
Mailing Address - Fax:
Practice Address - Street 1:3525 PRESLEY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4453
Practice Address - Country:US
Practice Address - Phone:951-782-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3051-I101YM0800X
CA133051 II101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA133051 IIOtherCAADE