Provider Demographics
NPI:1366092223
Name:CLARKE, RILEY
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:CLARKE
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 1:8549 WILSHIRE BLVD # 2427
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6300 VARIEL AVE APT 418
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7773
Practice Address - Country:US
Practice Address - Phone:818-634-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2023-10-10
Deactivation Date:2021-05-07
Deactivation Code:
Reactivation Date:2021-05-25
Provider Licenses
StateLicense IDTaxonomies
CA34441103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist