Provider Demographics
NPI:1801967195
Name:CLARK, MELISSA (6002172)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:6002172
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6306
Mailing Address - Country:US
Mailing Address - Phone:812-372-1571
Mailing Address - Fax:
Practice Address - Street 1:6141 BASSWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-8431
Practice Address - Country:US
Practice Address - Phone:812-603-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0035711041C0700X
IN34005724A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002172Medicaid