Provider Demographics
NPI:1144035635
Name:MICHAEL CLARK MARRIAGE AND FAMILY THERAPY, INC
Entity type:Organization
Organization Name:MICHAEL CLARK MARRIAGE AND FAMILY THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMFT
Authorized Official - Phone:510-556-5800
Mailing Address - Street 1:70 HARLAN ST APT 101
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1918 BONITA AVE STE 208
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1014
Practice Address - Country:US
Practice Address - Phone:510-556-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health