Provider Demographics
NPI:1770149619
Name:CLARK, WILL (MS, APC, NCC)
Entity type:Individual
Prefix:
First Name:WILL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, APC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 KINGS BAY CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-7123
Mailing Address - Country:US
Mailing Address - Phone:404-664-7494
Mailing Address - Fax:
Practice Address - Street 1:2336 WISTERIA DR STE 440
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6160
Practice Address - Country:US
Practice Address - Phone:404-664-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional