Provider Demographics
NPI:1063428928
Name:CLARK, KAREN LEE (MFT)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MISS
Other - First Name:KAREN
Other - Middle Name:LEE
Other - Last Name:GATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2229 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2438
Mailing Address - Country:US
Mailing Address - Phone:805-373-7068
Mailing Address - Fax:866-831-8663
Practice Address - Street 1:141 DUESENBERG DR
Practice Address - Street 2:SUITE 9
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-3416
Practice Address - Country:US
Practice Address - Phone:805-630-2252
Practice Address - Fax:866-831-8663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 30324106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist