Provider Demographics
NPI:1427421668
Name:CLARK, TANNER (MS)
Entity type:Individual
Prefix:MR
First Name:TANNER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 N NAIL PKWY
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4636
Mailing Address - Country:US
Mailing Address - Phone:580-262-0250
Mailing Address - Fax:
Practice Address - Street 1:326 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6710
Practice Address - Country:US
Practice Address - Phone:580-262-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist