Provider Demographics
NPI:1306293162
Name:CLARK, CONNETRA LASHAN
Entity type:Individual
Prefix:MS
First Name:CONNETRA
Middle Name:LASHAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SE 4TH ST
Mailing Address - Street 2:42
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-8791
Mailing Address - Country:US
Mailing Address - Phone:352-642-4775
Mailing Address - Fax:
Practice Address - Street 1:1900 SE 4TH ST
Practice Address - Street 2:42
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-8791
Practice Address - Country:US
Practice Address - Phone:352-642-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)