1356650162 NPI number — MS. SUSAN LYNN CLARK MS, COUNSELING, MFT

Table of content: MS. SUSAN LYNN CLARK MS, COUNSELING, MFT (NPI 1356650162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356650162 NPI number — MS. SUSAN LYNN CLARK MS, COUNSELING, MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
SUSAN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, COUNSELING, MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALKER
Provider Other First Name:
SUSAN
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, COUNSELING, MFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356650162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11148 BUTLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRASS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95945-6915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-798-8215
Provider Business Mailing Address Fax Number:
530-271-0775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11148 BUTLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-6915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-798-8215
Provider Business Practice Location Address Fax Number:
530-271-0775
Provider Enumeration Date:
09/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFT 18395 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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