Provider Demographics
NPI:1679228134
Name:CLARK, TERYL LASHAWNN (MS)
Entity Type:Individual
Prefix:
First Name:TERYL
Middle Name:LASHAWNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 W 16TH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7666
Mailing Address - Country:US
Mailing Address - Phone:786-332-6632
Mailing Address - Fax:305-418-7578
Practice Address - Street 1:326 N RIDGEWOOD DR STE C
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7205
Practice Address - Country:US
Practice Address - Phone:786-332-6632
Practice Address - Fax:305-418-7578
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty