Provider Demographics
NPI:1215151923
Name:CLARK, KEREN LOUISE (LMFT)
Entity type:Individual
Prefix:
First Name:KEREN
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2239
Mailing Address - Country:US
Mailing Address - Phone:928-830-6306
Mailing Address - Fax:
Practice Address - Street 1:4299 MACARTHUR BLVD
Practice Address - Street 2:200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2023
Practice Address - Country:US
Practice Address - Phone:928-830-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27091106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist