Provider Demographics
NPI:1346453727
Name:CLARK, HOLLY MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 UNIVERSITY PARKWAY
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6807
Mailing Address - Country:US
Mailing Address - Phone:803-335-1219
Mailing Address - Fax:803-335-1689
Practice Address - Street 1:410 UNIVERSITY PARKWAY
Practice Address - Street 2:SUITE 2300
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6807
Practice Address - Country:US
Practice Address - Phone:803-335-1219
Practice Address - Fax:803-335-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARTP0018592084P0015X
NY3174932084P0800X
SC337382084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC337380Medicaid