Provider Demographics
NPI:1710715255
Name:CLARK, AVA L (RMHCI)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 MARSH POINT RD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-1630
Mailing Address - Country:US
Mailing Address - Phone:904-534-2328
Mailing Address - Fax:
Practice Address - Street 1:11932 FAIRWAY LAKES DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8337
Practice Address - Country:US
Practice Address - Phone:239-237-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health