Provider Demographics
NPI:1619543634
Name:CLARK, MARIAH (GC)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:GC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 18TH ST APT 344
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-0050
Mailing Address - Country:US
Mailing Address - Phone:540-294-0791
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1971
Practice Address - Country:US
Practice Address - Phone:757-668-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS