Provider Demographics
NPI:1013270917
Name:CLARK, TARA ANNETTE (MS)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ANNETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LIBBY AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-1737
Mailing Address - Country:US
Mailing Address - Phone:516-495-4196
Mailing Address - Fax:
Practice Address - Street 1:24 LIBBY AVE
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1737
Practice Address - Country:US
Practice Address - Phone:516-495-4196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2012-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1711977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist