Provider Demographics
NPI:1245829548
Name:CLARK, DEIDRE' MARIE (MA, LMFT)
Entity type:Individual
Prefix:MS
First Name:DEIDRE'
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 RIVER WOODS LN
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-3369
Mailing Address - Country:US
Mailing Address - Phone:952-220-0263
Mailing Address - Fax:
Practice Address - Street 1:200 4TH AVE W STE 300
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3698106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist