Provider Demographics
NPI:1841942109
Name:CLINKENBEARD, HEATHER A
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:CLINKENBEARD
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 1:1 ALICANTE
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3850
Mailing Address - Country:US
Mailing Address - Phone:949-280-5774
Mailing Address - Fax:
Practice Address - Street 1:2082 MICHELSON DR STE 214
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1212
Practice Address - Country:US
Practice Address - Phone:949-946-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical