Provider Demographics
NPI:1447640289
Name:CLARK, UMMI (CMT, CLC, CSC)
Entity type:Individual
Prefix:
First Name:UMMI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CMT, CLC, CSC
Other - Prefix:
Other - First Name:KABSUE WITH UMMI
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMT, CLC, CSC
Mailing Address - Street 1:365 W 2ND AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4136
Mailing Address - Country:US
Mailing Address - Phone:760-705-5830
Mailing Address - Fax:
Practice Address - Street 1:365 W 2ND AVE STE 207
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4151
Practice Address - Country:US
Practice Address - Phone:760-705-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41928225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447640289OtherNPI