Provider Demographics
NPI:1871732412
Name:CLARK, GINA MARIE (ACSW)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACSW
Mailing Address - Street 1:1008 W AVENUE J10
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4828
Mailing Address - Country:US
Mailing Address - Phone:661-341-3900
Mailing Address - Fax:
Practice Address - Street 1:1008 W AVENUE J10
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4828
Practice Address - Country:US
Practice Address - Phone:661-341-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29038104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker