Provider Demographics
NPI:1487169173
Name:CLACK, TERRI MARIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:MARIE
Last Name:CLACK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON MALL STE 1045
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2603
Mailing Address - Country:US
Mailing Address - Phone:617-249-4036
Mailing Address - Fax:617-843-9320
Practice Address - Street 1:1 WASHINGTON MALL STE 1045
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2603
Practice Address - Country:US
Practice Address - Phone:617-249-4036
Practice Address - Fax:617-843-9320
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214255363LP2300X, 363LP0808X
MARN2362195363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care