Active NPI
Walter Otha Clark III, CATC II
- Addiction (Substance Use Disorder) Counselor
- Riverside, CA
National Provider Identifier
1811230980
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Addiction (Substance Use Disorder) Counselor
- License
- 133051 II
- Practice address
- 3525 Presley Ave
Riverside, CA 92507-4453 - Phone
- (951) 782-2400
- NPI assigned
- Mar 27, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 3051-I | CA | |
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 133051 II | CA | Primary |
Addresses
Primary practice location
3525 Presley Ave
Riverside, CA 92507-4453
Mailing address
3525 Presley Ave
Riverside, CA 92507-4453
Phone (951) 782-2400
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 133051 II | Other | CA | CAADE |
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 |
|---|---|---|---|
| 133051 II | CA | MD | Addiction (Substance Use Disorder) Counselor |
| 3051-I | CA | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1364342400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1377129600000",
"number": "1811230980",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3525 PRESLEY AVE",
"city": "RIVERSIDE",
"state": "CA",
"postal_code": "925074453",
"telephone_number": "951-782-2400"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3525 PRESLEY AVE",
"city": "RIVERSIDE",
"state": "CA",
"postal_code": "925074453",
"telephone_number": "951-782-2400"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "WALTER",
"middle_name": "OTHA",
"name_suffix": "III",
"credential": "CATC II",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-03-27",
"last_updated": "2013-08-22",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "CA",
"license": "3051-I",
"primary": false
},
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "CA",
"license": "133051 II",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CAADE",
"identifier": "133051 II",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Riverside, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.