Provider Demographics
NPI:1912286899
Name:CLARK, KACEE LYNN
Entity Type:Individual
Prefix:
First Name:KACEE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 POWER INN RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3890
Mailing Address - Country:US
Mailing Address - Phone:916-291-7219
Mailing Address - Fax:
Practice Address - Street 1:3321 POWER INN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3890
Practice Address - Country:US
Practice Address - Phone:916-291-7219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67334104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker