Provider Demographics
NPI:1821793258
Name:CLARK, MARY THERESA (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
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 1:133 E LOCUST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19363-1305
Mailing Address - Country:US
Mailing Address - Phone:610-357-8698
Mailing Address - Fax:
Practice Address - Street 1:2264 BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:PA
Practice Address - Zip Code:19363-4007
Practice Address - Country:US
Practice Address - Phone:610-932-0758
Practice Address - Fax:610-932-7744
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health