Provider Demographics
NPI:1801022413
Name:LISA CLARK ENTERPRISES, INC
Entity Type:Organization
Organization Name:LISA CLARK ENTERPRISES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-276-3037
Mailing Address - Street 1:2309 NORBURY CV SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5206
Mailing Address - Country:US
Mailing Address - Phone:678-519-1038
Mailing Address - Fax:678-239-4720
Practice Address - Street 1:2785 LAWRENCEVILLE HWY STE 207
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2515
Practice Address - Country:US
Practice Address - Phone:678-519-1038
Practice Address - Fax:678-239-4720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002509103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000910929OMedicaid
GA000910929KMedicaid
GA000910929GMedicaid
GA000910929EMedicaid
GA000910929FMedicaid
GA000910929LMedicaid
GA000910929IMedicaid