Provider Demographics
NPI:1710597018
Name:CLARK, MARYSA (MA)
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NEWBURY ST STE 500
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-4593
Mailing Address - Country:US
Mailing Address - Phone:781-551-0999
Mailing Address - Fax:
Practice Address - Street 1:125 NEWBURY ST STE 500
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-4593
Practice Address - Country:US
Practice Address - Phone:781-829-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY5000421103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty