Provider Demographics
NPI:1891368056
Name:CLARK, ROBERT BICKNELL III (CADC-1)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BICKNELL
Last Name:CLARK
Suffix:III
Gender:M
Credentials:CADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 NORTHSIDE PKWY NW BLDG 7
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-3007
Mailing Address - Country:US
Mailing Address - Phone:404-793-6349
Mailing Address - Fax:
Practice Address - Street 1:4200 NORTHSIDE PKWY NW BLDG 7
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-3007
Practice Address - Country:US
Practice Address - Phone:404-793-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0689101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty