Provider Demographics
NPI:1457651150
Name:EDMOND, CLARK DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:DAVID
Last Name:EDMOND
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24885 WHITEWOOD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2014
Mailing Address - Country:US
Mailing Address - Phone:951-676-5154
Mailing Address - Fax:951-526-1015
Practice Address - Street 1:24885 WHITEWOOD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2014
Practice Address - Country:US
Practice Address - Phone:951-676-5154
Practice Address - Fax:951-526-1015
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 254411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical