Provider Demographics
NPI:1023799467
Name:BARK, LAUREN ELLEN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELLEN
Last Name:BARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 AYALA CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3811
Mailing Address - Country:US
Mailing Address - Phone:858-603-2388
Mailing Address - Fax:
Practice Address - Street 1:320 10TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5291
Practice Address - Country:US
Practice Address - Phone:707-579-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty