Provider Demographics
NPI:1548441710
Name:CLARK, THERESA M (MFT)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 VINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1433
Mailing Address - Country:US
Mailing Address - Phone:860-223-9291
Mailing Address - Fax:860-223-3111
Practice Address - Street 1:5 COLONY STREET
Practice Address - Street 2:SUITES 301/303
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-3272
Practice Address - Country:US
Practice Address - Phone:203-235-7923
Practice Address - Fax:203-235-0013
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist