Provider Demographics
NPI:1790077295
Name:CLARK, DEBORAH LEE
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
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 1:377 KEAHOLE ST
Mailing Address - Street 2:E-210
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-3405
Mailing Address - Country:US
Mailing Address - Phone:808-428-4125
Mailing Address - Fax:808-396-3070
Practice Address - Street 1:377 KEAHOLE ST
Practice Address - Street 2:E-210
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-3405
Practice Address - Country:US
Practice Address - Phone:808-428-4125
Practice Address - Fax:808-396-3070
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI37211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical