Active NPI
Elizabeth Clark
- Addiction (Substance Use Disorder) Counselor
- San Bernardino, CA
National Provider Identifier
1508061615
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Addiction (Substance Use Disorder) Counselor
- License
- 01-047276
- Practice address
- 780 E Gilbert St
Suite 23 & 24
San Bernardino, CA 92415-1003 - Phone
- (909) 387-7458
- NPI assigned
- Jun 19, 2007
- Last updated
- Jun 16, 2014
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 01-047276 | CA | Primary |
Addresses
Primary practice location
780 E Gilbert St
Suite 23 & 24
San Bernardino, CA 92415-1003
Mailing address
4369 Sierra Ave
Norco, CA 92860-1347
Phone (909) 387-7458
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3145 | Other | CA | SIMON STAFF NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01-047276 | CA | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1182211200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1402876800000",
"number": "1508061615",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4369 SIERRA AVE",
"city": "NORCO",
"state": "CA",
"postal_code": "928601347",
"telephone_number": "909-387-7458"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "780 E GILBERT ST",
"address_2": "SUITE 23 & 24",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924151003",
"telephone_number": "909-387-7458"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "ELIZABETH",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-06-19",
"last_updated": "2014-06-16",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "CA",
"license": "01-047276",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "SIMON STAFF NUMBER",
"identifier": "3145",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in San Bernardino, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.