Provider Demographics
NPI:1508692070
Name:CLARK, ADRIENNE
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 E 4TH ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1042
Mailing Address - Country:US
Mailing Address - Phone:917-246-9421
Mailing Address - Fax:
Practice Address - Street 1:78 E 4TH ST APT 2R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-1042
Practice Address - Country:US
Practice Address - Phone:917-246-9421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency