Provider Demographics
NPI:1750914610
Name:CLARK, ANITA LYNN (PHD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 MILES AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-2706
Mailing Address - Country:US
Mailing Address - Phone:805-268-5219
Mailing Address - Fax:
Practice Address - Street 1:3839 CONSTELLATION RD STE C
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-0434
Practice Address - Country:US
Practice Address - Phone:805-268-5219
Practice Address - Fax:805-733-0216
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist