Provider Demographics
NPI:1568949923
Name:MARIA CLARK LLC
Entity Type:Organization
Organization Name:MARIA CLARK LLC
Other - Org Name:MARIA CLARK LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LIMHP
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:402-536-9568
Mailing Address - Street 1:2613 BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-3707
Mailing Address - Country:US
Mailing Address - Phone:402-536-9568
Mailing Address - Fax:402-905-4767
Practice Address - Street 1:1620 WILSHIRE DR STE 222
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-6600
Practice Address - Country:US
Practice Address - Phone:402-536-9568
Practice Address - Fax:402-905-4767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1579101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty