Provider Demographics
NPI:1023726767
Name:CLARK, MARY (LMHC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LIBERTY SQ
Mailing Address - Street 2:PMB 91874
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5800
Mailing Address - Country:US
Mailing Address - Phone:617-209-9567
Mailing Address - Fax:
Practice Address - Street 1:157 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2667
Practice Address - Country:US
Practice Address - Phone:617-209-9567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10002305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health