Provider Demographics
NPI:1316424740
Name:CLARK, ANITA COLEEN
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:COLEEN
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 1:755 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-8221
Mailing Address - Country:US
Mailing Address - Phone:870-557-6629
Mailing Address - Fax:
Practice Address - Street 1:200 IMMANUAL ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3937
Practice Address - Country:US
Practice Address - Phone:870-845-3262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor