Provider Demographics
NPI:1043368145
Name:CLARK, ELISABETH OLIVER (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:OLIVER
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 N OGDEN DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-2616
Mailing Address - Country:US
Mailing Address - Phone:323-850-0620
Mailing Address - Fax:323-850-0620
Practice Address - Street 1:544 S SAN VICENTE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4622
Practice Address - Country:US
Practice Address - Phone:323-850-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12291Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER