Provider Demographics
NPI:1487126876
Name:CLARK, ANNAMARIA VENCENZA
Entity type:Individual
Prefix:
First Name:ANNAMARIA
Middle Name:VENCENZA
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 1:225 MICCO AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-7031
Mailing Address - Country:US
Mailing Address - Phone:863-446-1019
Mailing Address - Fax:
Practice Address - Street 1:2520 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3402
Practice Address - Country:US
Practice Address - Phone:407-891-3054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty