Provider Demographics
NPI:1659987501
Name:CLARK, MELVIN DALTON
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:DALTON
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9427 JEWEL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-1518
Mailing Address - Country:US
Mailing Address - Phone:907-230-3315
Mailing Address - Fax:
Practice Address - Street 1:1709 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3436
Practice Address - Country:US
Practice Address - Phone:907-230-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health