Provider Demographics
NPI:1003817081
Name:CLARK, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
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 1:666 HIGH ST
Mailing Address - Street 2:SUITE 200-D
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-4135
Mailing Address - Country:US
Mailing Address - Phone:614-430-8920
Mailing Address - Fax:614-430-8920
Practice Address - Street 1:666 HIGH ST
Practice Address - Street 2:SUITE 200-D
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4135
Practice Address - Country:US
Practice Address - Phone:614-430-8920
Practice Address - Fax:614-430-8920
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical