Provider Demographics
NPI:1982936837
Name:CLARK, KATHERINE ELIZABETH (MFT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N ACACIA AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1165
Mailing Address - Country:US
Mailing Address - Phone:858-822-9046
Mailing Address - Fax:858-792-3884
Practice Address - Street 1:125 N ACACIA AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1165
Practice Address - Country:US
Practice Address - Phone:858-822-9046
Practice Address - Fax:858-792-3884
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47115106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist