Provider Demographics
NPI:1891538492
Name:CLARK, ALEXANDRIA FAITH
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:FAITH
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SKYLAR
Other - Middle Name:FAITH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:53 WINCHESTER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6239
Mailing Address - Country:US
Mailing Address - Phone:203-832-3838
Mailing Address - Fax:
Practice Address - Street 1:21 GEORGE ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2228
Practice Address - Country:US
Practice Address - Phone:978-453-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor