Provider Demographics
NPI:1992908891
Name:CLARK, TANA M (PHD)
Entity type:Individual
Prefix:DR
First Name:TANA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TANA
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:100 TAMAL PLZ
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1125
Mailing Address - Country:US
Mailing Address - Phone:415-924-6935
Mailing Address - Fax:
Practice Address - Street 1:100 TAMAL PLZ
Practice Address - Street 2:SUITE 160
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1125
Practice Address - Country:US
Practice Address - Phone:415-924-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY#14966103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist