Provider Demographics
NPI:1528524162
Name:CLERKLEY, KIANA M
Entity type:Individual
Prefix:
First Name:KIANA
Middle Name:M
Last Name:CLERKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 CRYER PL
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-3064
Mailing Address - Country:US
Mailing Address - Phone:510-393-4055
Mailing Address - Fax:
Practice Address - Street 1:1356 RIDDER PARK DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2313
Practice Address - Country:US
Practice Address - Phone:669-304-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA103K00000X
CA1110261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9140860054OtherAETNA