Provider Demographics
NPI:1679706717
Name:CLARK, GRACIELA MARIA (BS)
Entity Type:Individual
Prefix:MRS
First Name:GRACIELA
Middle Name:MARIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:GRACIELA
Other - Middle Name:MARIA
Other - Last Name:DE LA LLANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:430 W 5TH S APT 507
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2347
Mailing Address - Country:US
Mailing Address - Phone:208-757-1330
Mailing Address - Fax:
Practice Address - Street 1:430 W 5TH S APT 507
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2347
Practice Address - Country:US
Practice Address - Phone:208-757-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker