Provider Demographics
NPI:1033844386
Name:CLARK, CASSIDY (MS)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 PINE BLUFF BLVD APT 112
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1683
Mailing Address - Country:US
Mailing Address - Phone:484-408-7990
Mailing Address - Fax:
Practice Address - Street 1:115 OAK RD
Practice Address - Street 2:
Practice Address - City:NORRIS
Practice Address - State:TN
Practice Address - Zip Code:37828-3051
Practice Address - Country:US
Practice Address - Phone:865-351-0621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health