Provider Demographics
NPI:1811489073
Name:FORD-CLARK, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FORD-CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-8224
Mailing Address - Country:US
Mailing Address - Phone:617-913-7569
Mailing Address - Fax:
Practice Address - Street 1:1515 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5243
Practice Address - Country:US
Practice Address - Phone:617-913-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7170-PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty