Provider Demographics
NPI:1649077140
Name:CLARK, DIANN (MS, CAT)
Entity type:Individual
Prefix:
First Name:DIANN
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:MS, CAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8272 WOLFCHASE LN APT 203
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2000
Mailing Address - Country:US
Mailing Address - Phone:870-588-7249
Mailing Address - Fax:
Practice Address - Street 1:8900 DELTA BLUFF CV
Practice Address - Street 2:
Practice Address - City:WALLS
Practice Address - State:MS
Practice Address - Zip Code:38680-4400
Practice Address - Country:US
Practice Address - Phone:870-588-7249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)