Provider Demographics
NPI:1457102659
Name:CLARK, CHATIELA (EDS)
Entity type:Individual
Prefix:
First Name:CHATIELA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 N ROCK ISLAND RD APT 305
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-1226
Mailing Address - Country:US
Mailing Address - Phone:570-497-0522
Mailing Address - Fax:
Practice Address - Street 1:120 S UNIVERSITY DR STE F
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3346
Practice Address - Country:US
Practice Address - Phone:954-559-2936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1819103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool