Provider Demographics
NPI:1851653471
Name:CLARK, LORENA T (MS ED)
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 SOUTHARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:97 SOUTHARD AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3142
Practice Address - Country:US
Practice Address - Phone:516-652-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist