Provider Demographics
NPI:1689150344
Name:CLARK, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14024 DUNDEE CV
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4869
Mailing Address - Country:US
Mailing Address - Phone:228-326-7687
Mailing Address - Fax:
Practice Address - Street 1:1635 POPPS FERRY RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2312
Practice Address - Country:US
Practice Address - Phone:228-207-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health