Provider Demographics
NPI:1144779778
Name:CLARK, TERESA (ST)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 W GORDON AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-4607
Mailing Address - Country:US
Mailing Address - Phone:229-395-8561
Mailing Address - Fax:
Practice Address - Street 1:2304 W GORDON AVE APT 218
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4607
Practice Address - Country:US
Practice Address - Phone:229-395-8561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor