Provider Demographics
NPI:1184156143
Name:CLARK, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
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 1:205 CRUSADER PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4339
Mailing Address - Country:US
Mailing Address - Phone:404-449-3121
Mailing Address - Fax:678-892-8575
Practice Address - Street 1:2795 MAIN ST W STE 20B
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3073
Practice Address - Country:US
Practice Address - Phone:678-344-7836
Practice Address - Fax:678-892-8575
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical