Provider Demographics
NPI:1013343607
Name:CLARK, MARIEL LAKEITHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIEL
Middle Name:LAKEITHA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 KATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1976
Mailing Address - Country:US
Mailing Address - Phone:334-774-7704
Mailing Address - Fax:334-774-7704
Practice Address - Street 1:191 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1976
Practice Address - Country:US
Practice Address - Phone:334-774-7704
Practice Address - Fax:334-774-7704
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1838103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist