Provider Demographics
NPI:1386168672
Name:CLARK, ALEXIS RAE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 BERNAL AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6986
Mailing Address - Country:US
Mailing Address - Phone:260-273-9984
Mailing Address - Fax:
Practice Address - Street 1:3020 BERNAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6986
Practice Address - Country:US
Practice Address - Phone:260-273-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129078104100000X
CA92198101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health