Provider Demographics
NPI:1063776524
Name:CLARK, LINDSEY M (MSED)
Entity type:Individual
Prefix:MISS
First Name:LINDSEY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 RUMSON RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5915
Mailing Address - Country:US
Mailing Address - Phone:718-983-6872
Mailing Address - Fax:
Practice Address - Street 1:4024 AMBOY RD
Practice Address - Street 2:CHIP
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2409
Practice Address - Country:US
Practice Address - Phone:718-984-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608834121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist