Provider Demographics
NPI:1689129546
Name:CLARK, MARY (LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 2ND AVE E STE 5
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-4042
Mailing Address - Country:US
Mailing Address - Phone:218-319-7171
Mailing Address - Fax:
Practice Address - Street 1:2232 2ND AVE E STE 5
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-4042
Practice Address - Country:US
Practice Address - Phone:218-319-7171
Practice Address - Fax:218-260-4749
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3298106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist