Provider Demographics
NPI:1043251259
Name:CLARK, HEATHER AMY (MA)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:AMY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 THREEPENCE DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4024
Mailing Address - Country:US
Mailing Address - Phone:516-852-3265
Mailing Address - Fax:631-666-1709
Practice Address - Street 1:1555 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6027
Practice Address - Country:US
Practice Address - Phone:631-666-1615
Practice Address - Fax:631-666-1709
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000547-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health