Provider Demographics
NPI:1649069378
Name:CLARK, KORINN LORRAINE
Entity type:Individual
Prefix:
First Name:KORINN
Middle Name:LORRAINE
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-1510
Mailing Address - Country:US
Mailing Address - Phone:516-270-5233
Mailing Address - Fax:
Practice Address - Street 1:2512 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419-1510
Practice Address - Country:US
Practice Address - Phone:516-270-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1567353221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health