Provider Demographics
NPI:1922116508
Name:CLARK, LILLEE (PHD)
Entity Type:Individual
Prefix:
First Name:LILLEE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 GREEN ST NW STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3319
Mailing Address - Country:US
Mailing Address - Phone:770-538-4800
Mailing Address - Fax:770-503-9299
Practice Address - Street 1:605 GREEN ST NW STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3319
Practice Address - Country:US
Practice Address - Phone:770-538-4800
Practice Address - Fax:770-503-9299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001290103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00566354AMedicaid
GA68BBDKNMedicare ID - Type Unspecified
GA00566354AMedicaid