Provider Demographics
NPI:1093867384
Name:CLARK, ALYSSA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:G
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 S LUMPKIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-4740
Mailing Address - Country:US
Mailing Address - Phone:706-354-4204
Mailing Address - Fax:
Practice Address - Street 1:1751 S LUMPKIN ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-4740
Practice Address - Country:US
Practice Address - Phone:706-354-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical