Provider Demographics
NPI:1174886808
Name:CLARK, KORI
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:
Last Name: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 1:9374 ALANGO RD
Mailing Address - Street 2:
Mailing Address - City:ANGORA
Mailing Address - State:MN
Mailing Address - Zip Code:55703-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1724 VINE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-1120
Practice Address - Country:US
Practice Address - Phone:503-997-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health