Provider Demographics
NPI:1750546693
Name:CLARK, MARY KATHERINE (MS,LPE-I)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS,LPE-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 3023
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-3020
Mailing Address - Country:US
Mailing Address - Phone:479-996-1414
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-7031
Practice Address - Country:US
Practice Address - Phone:479-996-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR83-07E-I103TC0700X, 103TF0000X, 103TP2701X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy