Provider Demographics
NPI:1952378226
Name:CLARK, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4557 MEADOW CREEK PATH
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-7704
Mailing Address - Country:US
Mailing Address - Phone:678-519-1038
Mailing Address - Fax:770-756-9195
Practice Address - Street 1:225 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2522
Practice Address - Country:US
Practice Address - Phone:678-519-1038
Practice Address - Fax:770-756-9195
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002509103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000910929HMedicaid
GA000910929KMedicaid
GA000910929LMedicaid
GA000910929IMedicaid
GA000910929GMedicaid
GA000910929EMedicaid
GA000910929FMedicaid