Provider Demographics
NPI:1174526578
Name:CLARK, MARY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY ANN
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 1:300 RIVERSIDE DR E
Mailing Address - Street 2:STE 2000
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1023
Mailing Address - Country:US
Mailing Address - Phone:941-746-8822
Mailing Address - Fax:941-746-8844
Practice Address - Street 1:300 RIVERSIDE DR E
Practice Address - Street 2:STE 2000
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1023
Practice Address - Country:US
Practice Address - Phone:941-746-8822
Practice Address - Fax:941-746-8844
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-10-18
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
FLPY0004772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59504OtherBCBS PROVIDER NUMBER
FL59504Medicare ID - Type UnspecifiedPROVIDER NUMBER