Provider Demographics
NPI:1982716254
Name:CLARK, SHELIA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1929
Mailing Address - Street 2:
Mailing Address - City:FRAZIER PARK
Mailing Address - State:CA
Mailing Address - Zip Code:93225-1929
Mailing Address - Country:US
Mailing Address - Phone:661-644-3943
Mailing Address - Fax:661-242-1583
Practice Address - Street 1:2805 RAINIER WAY
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN CLUB
Practice Address - State:CA
Practice Address - Zip Code:93222-6045
Practice Address - Country:US
Practice Address - Phone:661-644-3943
Practice Address - Fax:661-242-1583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13425103T00000X, 103TC0700X
CAMFC23878106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY134253Medicaid
CACP13425Medicare PIN