Provider Demographics
NPI:1063963395
Name:CLARK, CHRISTINE MICHELLE (MS)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 TERRA ROSA CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-5144
Mailing Address - Country:US
Mailing Address - Phone:561-374-1893
Mailing Address - Fax:
Practice Address - Street 1:6321 TERRA ROSA CIR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-5144
Practice Address - Country:US
Practice Address - Phone:561-374-1893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15114101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor