Provider Demographics
NPI:1225386139
Name:CLARK, MELANIE R
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
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 1:603 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:IL
Mailing Address - Zip Code:61006-9230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:IL
Practice Address - Zip Code:61006-9230
Practice Address - Country:US
Practice Address - Phone:815-501-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health