Provider Demographics
NPI:1073088126
Name:CLARK, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
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 1:2933 CHEROKEE ST NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 KINGSTON HWY SE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-7504
Practice Address - Country:US
Practice Address - Phone:770-627-6627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-20-43230103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-18-9125OtherBCABA