Provider Demographics
NPI:1528114451
Name:CLARK, MARYLYN ANN (PH D)
Entity type:Individual
Prefix:DR
First Name:MARYLYN
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10246
Mailing Address - Street 2:PRESCOTT
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0246
Mailing Address - Country:US
Mailing Address - Phone:928-778-1806
Mailing Address - Fax:928-541-5308
Practice Address - Street 1:222 WEST GURLEY ST. SUITE 105
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-3244
Practice Address - Country:US
Practice Address - Phone:928-778-1806
Practice Address - Fax:928-541-9308
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC11094101YA0400X
AZLMFT0053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
EIN203600957OtherIRS