Provider Demographics
NPI:1649541673
Name:CLARK, MARIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
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 1:12685 DORSETT RD
Mailing Address - Street 2:#339
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2100
Mailing Address - Country:US
Mailing Address - Phone:314-644-1557
Mailing Address - Fax:314-453-4942
Practice Address - Street 1:141 MARKET PL
Practice Address - Street 2:SUITE 206
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2034
Practice Address - Country:US
Practice Address - Phone:314-644-1557
Practice Address - Fax:314-453-4942
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000714106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist