Provider Demographics
NPI:1881416238
Name:CLARK, REBECCA DAWN (APCC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:DAWN
Other - Last Name:EMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9810
Mailing Address - Country:US
Mailing Address - Phone:808-651-1601
Mailing Address - Fax:
Practice Address - Street 1:2180 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4558
Practice Address - Country:US
Practice Address - Phone:805-461-6060
Practice Address - Fax:805-461-6061
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional