Provider Demographics
NPI:1407030018
Name:MARY ANN CLARK PH D & ASSOCIATES PA
Entity Type:Organization
Organization Name:MARY ANN CLARK PH D & ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-746-8822
Mailing Address - Street 1:300 RIVERSIDE DR E
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1008
Mailing Address - Country:US
Mailing Address - Phone:941-746-8822
Mailing Address - Fax:941-746-8844
Practice Address - Street 1:300 RIVERSIDE DR E
Practice Address - Street 2:SUITE 2000
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1008
Practice Address - Country:US
Practice Address - Phone:941-746-8822
Practice Address - Fax:941-746-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty