Provider Demographics
NPI:1588694236
Name:SOARES, CLINT J (PHD)
Entity type:Individual
Prefix:MR
First Name:CLINT
Middle Name:J
Last Name:SOARES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24511 W JAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-9503
Mailing Address - Country:US
Mailing Address - Phone:559-935-4301
Mailing Address - Fax:559-935-7118
Practice Address - Street 1:24511 W JAYNE AVE
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-9503
Practice Address - Country:US
Practice Address - Phone:559-935-4301
Practice Address - Fax:559-935-7118
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18782103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic