Provider Demographics
NPI:1851780324
Name:CLARK, SHAQUANA ANN
Entity Type:Individual
Prefix:
First Name:SHAQUANA
Middle Name:ANN
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 1:55 OAKLAND TER APT 52
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2167
Mailing Address - Country:US
Mailing Address - Phone:860-268-9064
Mailing Address - Fax:
Practice Address - Street 1:55 OAKLAND TER APT 52
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2167
Practice Address - Country:US
Practice Address - Phone:860-268-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health