Provider Demographics
NPI:1962569608
Name:CLARK, STEVEN
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2751
Mailing Address - Country:US
Mailing Address - Phone:310-376-8617
Mailing Address - Fax:310-825-3799
Practice Address - Street 1:2309 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2751
Practice Address - Country:US
Practice Address - Phone:310-376-8617
Practice Address - Fax:310-825-3799
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS73631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical