Provider Demographics
NPI:1083748404
Name:CLARK, KARYN E (PHD, ACADC)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-9001
Mailing Address - Country:US
Mailing Address - Phone:209-525-7218
Mailing Address - Fax:209-558-1082
Practice Address - Street 1:190 E HACKETT RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-9001
Practice Address - Country:US
Practice Address - Phone:209-525-7218
Practice Address - Fax:209-558-1082
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 171M00000X
CADTP6327101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator