Provider Demographics
NPI:1346620259
Name:CLARK, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
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 1:7030 CAPELLA PARK AV
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75236
Mailing Address - Country:US
Mailing Address - Phone:817-540-1363
Mailing Address - Fax:
Practice Address - Street 1:7030 CAPELLA PARK AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75236-3003
Practice Address - Country:US
Practice Address - Phone:817-540-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities