Provider Demographics
NPI:1922617471
Name:CLARK, DENISE MONIQUE (NCC)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MONIQUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SOUTHLAND PASS
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4918
Mailing Address - Country:US
Mailing Address - Phone:662-374-3429
Mailing Address - Fax:
Practice Address - Street 1:1030 FAYETTEVILLE RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2921
Practice Address - Country:US
Practice Address - Phone:404-486-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health