Provider Demographics
NPI:1851967459
Name:CLARK, CHARLOTTE RENEE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:RENEE
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 1:1990 WILLOW TRAIL PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2665
Mailing Address - Country:US
Mailing Address - Phone:678-900-6193
Mailing Address - Fax:
Practice Address - Street 1:4335 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3362
Practice Address - Country:US
Practice Address - Phone:770-822-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician