Provider Information for 1568589067
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Mr. RICHARD CLARK MFT
Sex: Male
NPI: 1568589067
Last Updated: 2010-09-24
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1568589067 | ||||||||
| Enumeration Date | 2007-03-22 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 704 W 40TH ST APT 1 SAN PEDRO, CA 90731-7150 United States Phone: 310-831-5134 | Fax: | ||||||||
| Primary Practice Address | 4211 AVALON BLVD LOS ANGELES, CA 90011-5622 United States Phone: 323-432-5185 | Fax:323-432-5086 | ||||||||
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