Provider Demographics
NPI:1629010533
Name:CLARK, ANDREW R (PHD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511347
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7902
Mailing Address - Country:US
Mailing Address - Phone:619-631-0128
Mailing Address - Fax:619-631-0153
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-631-0128
Practice Address - Fax:619-631-0153
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10061103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10061Medicare ID - Type Unspecified
CAPSY10061Medicare UPIN