Provider Demographics
NPI:1720526403
Name:GEX, SALLY CLARK
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:CLARK
Last Name:GEX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:CLARK
Other - Last Name:GEX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 PARK CIRCLE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PARK CIRCLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7628
Practice Address - Country:US
Practice Address - Phone:601-664-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor