Provider Demographics
NPI:1871154443
Name:CLARK, SAMANTHA JEANINE (MS, COUNSELING PSYCH)
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:JEANINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, COUNSELING PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 OSWELL ST STE 119
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3172
Mailing Address - Country:US
Mailing Address - Phone:661-868-6750
Mailing Address - Fax:
Practice Address - Street 1:2621 OSWELL ST STE 119
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3172
Practice Address - Country:US
Practice Address - Phone:661-868-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA999031549106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA999031549OtherKERN BEHAVIORAL HEALTH AND RECOVERY SERVICES