Provider Demographics
NPI:1265985956
Name:CLARK, GINA MARIA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIA
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 1:8212 FOREST OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-6839
Mailing Address - Country:US
Mailing Address - Phone:352-584-6755
Mailing Address - Fax:
Practice Address - Street 1:8212 FOREST OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-6839
Practice Address - Country:US
Practice Address - Phone:352-584-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
FLRBT-17-32892106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty