Provider Demographics
NPI:1205142106
Name:CLARK, SANDRA DENICE (EDS)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:DENICE
Last Name:CLARK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7636
Mailing Address - Fax:601-581-7676
Practice Address - Street 1:5701 N HILLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-2903
Practice Address - Country:US
Practice Address - Phone:601-581-7562
Practice Address - Fax:601-581-7676
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0804101Y00000X, 101YP2500X
MSLH0061101YM0800X
MS168226101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool