Provider Demographics
NPI:1568188373
Name:CLARK, MARIANN ELEANOR
Entity Type:Individual
Prefix:
First Name:MARIANN
Middle Name:ELEANOR
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 1:1945 INDIES DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-2404
Mailing Address - Country:US
Mailing Address - Phone:980-833-7999
Mailing Address - Fax:
Practice Address - Street 1:180 CENTER PLACE WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8859
Practice Address - Country:US
Practice Address - Phone:904-429-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-238474106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-22-238474OtherREGISTERED BEHAVIOR TECHNICIAN