Provider Demographics
NPI:1053197517
Name:CLARK, JOSHUA WAYNE
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:WAYNE
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 1:4037 STE A 214
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371
Mailing Address - Country:US
Mailing Address - Phone:760-964-0153
Mailing Address - Fax:
Practice Address - Street 1:4037 STE A 214
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371
Practice Address - Country:US
Practice Address - Phone:760-964-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities