Provider Demographics
NPI:1720119167
Name:CLARK, MARK (SUDC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:711 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1903
Mailing Address - Country:US
Mailing Address - Phone:406-293-7731
Mailing Address - Fax:406-297-2823
Practice Address - Street 1:1366 W INDIAN HILLS DR UNIT 69
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-1885
Practice Address - Country:US
Practice Address - Phone:406-293-7731
Practice Address - Fax:406-297-2823
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT760460OtherCHIP
MT0000073691OtherBLUE CROSS BLUE SHIELD
MT0320372Medicaid