Provider Demographics
NPI:1952457616
Name:CLARK, DEBORAH (MA, LCMHC)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRISTOL CT UNIT 131
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1521
Mailing Address - Country:US
Mailing Address - Phone:603-479-7166
Mailing Address - Fax:
Practice Address - Street 1:501 MAMMOTH RD
Practice Address - Street 2:UNIT1
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-2309
Practice Address - Country:US
Practice Address - Phone:603-479-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30424650Medicaid