Provider Demographics
NPI:1598856759
Name:CLARK, KELLY (MA CAGS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MA CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MAIN ST
Mailing Address - Street 2:STE 401
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757
Mailing Address - Country:US
Mailing Address - Phone:508-473-4984
Mailing Address - Fax:508-482-7316
Practice Address - Street 1:171 MAIN ST
Practice Address - Street 2:STE 401
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-473-4984
Practice Address - Fax:508-482-7316
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM0158OtherBCBS