Provider Demographics
NPI:1609050913
Name:CLARK, KIMBERLY IRENE (MFT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:IRENE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2809
Mailing Address - Country:US
Mailing Address - Phone:714-614-7382
Mailing Address - Fax:714-444-0722
Practice Address - Street 1:3077 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2809
Practice Address - Country:US
Practice Address - Phone:714-614-7382
Practice Address - Fax:714-444-0722
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health