Provider Demographics
NPI:1275344764
Name:CLARK, GREGORY REINALDO (COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:REINALDO
Last Name:CLARK
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4183 FINCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-8999
Mailing Address - Country:US
Mailing Address - Phone:559-765-5894
Mailing Address - Fax:
Practice Address - Street 1:1235 E ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-2024
Practice Address - Country:US
Practice Address - Phone:559-844-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1594550125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)