Provider Demographics
NPI:1023167939
Name:CLARKE, MICHAEL WILLIAM (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:CLARKE
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 1:207 N BUTTE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2803
Mailing Address - Country:US
Mailing Address - Phone:530-330-8800
Mailing Address - Fax:530-934-3285
Practice Address - Street 1:845 W EAST AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2002
Practice Address - Country:US
Practice Address - Phone:530-896-9400
Practice Address - Fax:530-879-3352
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 20870106H00000X
CAPSY15252103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 15252OtherBOARD OF PSYCHOLOGY
CAMFT 20870OtherBOARD OF BSE