Provider Demographics
NPI:1033633037
Name:CLARK, MARISSA (MS, CGC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 HOBLITT LN S
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2827 FORT MISSOULA RD.
Practice Address - Street 2:SUITE 317
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804
Practice Address - Country:US
Practice Address - Phone:406-327-3924
Practice Address - Fax:406-327-3923
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS