Provider Demographics
NPI:1992399166
Name:CLARK, MARJORIE W
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:W
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 1:526 S MAIN ST # 107
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-4401
Mailing Address - Country:US
Mailing Address - Phone:330-368-2400
Mailing Address - Fax:
Practice Address - Street 1:526 S MAIN ST # 107
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-4401
Practice Address - Country:US
Practice Address - Phone:330-368-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1740837160OtherCOUNSELOR IN TRAINING