Provider Demographics
NPI:1134413503
Name:CLARK, DANA MARIE
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:MARIE
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 1:1300 E QUAIL AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-2534
Mailing Address - Country:US
Mailing Address - Phone:405-623-8910
Mailing Address - Fax:
Practice Address - Street 1:403 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3636
Practice Address - Country:US
Practice Address - Phone:580-623-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor