Provider Demographics
NPI:1407106032
Name:CLARK, KRISTIN MARIE (MS SPECIAL EDUCATION)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS SPECIAL EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VARDEN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-4804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 COLEBROOK DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-2211
Practice Address - Country:US
Practice Address - Phone:585-467-4567
Practice Address - Fax:585-467-6973
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1820739174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist