Provider Demographics
NPI:1821321795
Name:CLARK, MARYELIZABETH (BS)
Entity Type:Individual
Prefix:MS
First Name:MARYELIZABETH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PITAS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-7119
Mailing Address - Country:US
Mailing Address - Phone:508-399-8427
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-559-0473
Practice Address - Fax:508-427-5361
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program