Provider Demographics
NPI:1043511660
Name:CLARK, MONICA ANNETTE
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ANNETTE
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 1:441 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2482
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:419-549-5670
Practice Address - Street 1:441 E 8TH ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2482
Practice Address - Country:US
Practice Address - Phone:419-221-3072
Practice Address - Fax:419-549-5670
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1000027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional