Provider Demographics
NPI:1922859313
Name:CLARK, RENE THERESA
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:THERESA
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 1:75 N BEACON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2671
Mailing Address - Country:US
Mailing Address - Phone:617-661-3991
Mailing Address - Fax:
Practice Address - Street 1:255 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2729
Practice Address - Country:US
Practice Address - Phone:617-981-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187893081101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)