Provider Demographics
NPI:1194866350
Name:CLARK, TEZLYN SAMANTHA (MED)
Entity Type:Individual
Prefix:MISS
First Name:TEZLYN
Middle Name:SAMANTHA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 DENALI ST
Mailing Address - Street 2:SUITE 1606
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2783
Mailing Address - Country:US
Mailing Address - Phone:907-278-9355
Mailing Address - Fax:
Practice Address - Street 1:2550 DENALI ST
Practice Address - Street 2:SUITE 1606
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2783
Practice Address - Country:US
Practice Address - Phone:907-278-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health