Provider Demographics
NPI:1558804690
Name:CLARK, CHARITY ANN
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:ANN
Other - Last Name:CUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2066 OAK MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-8821
Mailing Address - Country:US
Mailing Address - Phone:207-570-2552
Mailing Address - Fax:
Practice Address - Street 1:2400 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3097
Practice Address - Country:US
Practice Address - Phone:386-304-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor