Provider Demographics
NPI:1952585218
Name:CLARK, GLEN ANTONIO III
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ANTONIO
Last Name:CLARK
Suffix:III
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 1:1153 OAK ST.
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117
Mailing Address - Country:US
Mailing Address - Phone:415-431-9000
Mailing Address - Fax:415-431-1813
Practice Address - Street 1:1301 PIERCE ST.
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-563-8200
Practice Address - Fax:510-644-2044
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)