Provider Demographics
NPI:1750773115
Name:CLARK, DENICE CROWE (LMFT)
Entity type:Individual
Prefix:
First Name:DENICE
Middle Name:CROWE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 JUNIPER ST NE APT 719
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-7659
Mailing Address - Country:US
Mailing Address - Phone:478-297-8262
Mailing Address - Fax:
Practice Address - Street 1:1201 PEACHTREE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30361-3503
Practice Address - Country:US
Practice Address - Phone:478-297-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist