1952457616 NPI number — MS. DEBORAH CLARK M.A., LCMHC

Table of content: MS. DEBORAH CLARK M.A., LCMHC (NPI 1952457616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952457616 NPI number — MS. DEBORAH CLARK M.A., LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
DEBORAH
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952457616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BRISTOL CT UNIT 131
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DERRY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03038-1521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-479-7166
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 MAMMOTH RD
Provider Second Line Business Practice Location Address:
UNIT1
Provider Business Practice Location Address City Name:
LONDONDERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03053-2309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-479-7166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  538 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30424650 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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