Provider Demographics
NPI:1720788680
Name:CLARK, KATIE RENEE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175
Mailing Address - Country:US
Mailing Address - Phone:606-202-0807
Mailing Address - Fax:
Practice Address - Street 1:4502 GALLIA ST
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:OH
Practice Address - Zip Code:45662-5541
Practice Address - Country:US
Practice Address - Phone:740-529-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator