Provider Demographics
NPI:1679623284
Name:GROVE, CLARK STANFORD (PHD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:STANFORD
Last Name:GROVE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-5800
Mailing Address - Country:US
Mailing Address - Phone:415-923-6760
Mailing Address - Fax:415-507-0306
Practice Address - Street 1:1902 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-5800
Practice Address - Country:US
Practice Address - Phone:415-923-6760
Practice Address - Fax:415-507-0306
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13469103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL134690OtherBLUE SHIELD