Provider Demographics
NPI:1750442596
Name:CLARK, MARIA G (LPC, LISAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:G
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:G
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, LISAC
Mailing Address - Street 1:1400 E SOUTHERN AVE
Mailing Address - Street 2:STE. 735
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5691
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-302-7884
Practice Address - Street 1:3260 N HAYDEN RD
Practice Address - Street 2:SUITE 112
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6649
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10628101YP2500X
AZLPC-13317101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ559377Medicaid