Provider Demographics
NPI:1528609229
Name:CLARK, MARY L (MS, LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CLEVELAND CT
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4116
Mailing Address - Country:US
Mailing Address - Phone:256-613-8830
Mailing Address - Fax:
Practice Address - Street 1:2911 ZELDA RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2648
Practice Address - Country:US
Practice Address - Phone:334-262-7787
Practice Address - Fax:334-262-7795
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2887101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty