Provider Demographics
NPI:1902446172
Name:CLARK, ASHLEY N
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 BIDWELL ST APT 311
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3063
Mailing Address - Country:US
Mailing Address - Phone:916-598-2501
Mailing Address - Fax:
Practice Address - Street 1:4343 WILLIAMSBOURGH DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2006
Practice Address - Country:US
Practice Address - Phone:916-395-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12345OtherSTUDENT