Provider Demographics
NPI:1356176580
Name:CLARK, GABRIELLE MARIE (MS)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13368 NW 2ND CT UNIT 305
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-7671
Mailing Address - Country:US
Mailing Address - Phone:224-277-4719
Mailing Address - Fax:
Practice Address - Street 1:7201 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-7101
Practice Address - Country:US
Practice Address - Phone:954-417-5568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health