Provider Demographics
NPI:1255789269
Name:CLARK, SUSAN KAREN
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAREN
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 1:3934 CAMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-2019
Mailing Address - Country:US
Mailing Address - Phone:951-316-4841
Mailing Address - Fax:909-804-0056
Practice Address - Street 1:3934 CAMELLIA DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-2019
Practice Address - Country:US
Practice Address - Phone:951-316-4841
Practice Address - Fax:909-804-0056
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 106H00000X
CA121989106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional