Provider Demographics
NPI:1245798156
Name:CLARK, MARIELLA E (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIELLA
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 OAKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:76135-4932
Mailing Address - Country:US
Mailing Address - Phone:817-779-0850
Mailing Address - Fax:
Practice Address - Street 1:121 OAKWOOD CT
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:TX
Practice Address - Zip Code:76135-4932
Practice Address - Country:US
Practice Address - Phone:817-779-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX577291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty