MEDICARE: CHRISTINA CLARKE M.S., ED.S, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC006586	GA
2	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1003123407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA CLARKE M.S., ED.S, PHD

Provider Business Mailing Address
First Line	:	3308 N HILL PKWY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-1274
Country	:	US
Telephone Number	:	404-229-5201
Fax Number	:	404-229-5201

Provider Business Practice Location Address
First Line	:	3308 N HILL PKWY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-1274
Country	:	US
Telephone Number	:	404-229-5201
Fax Number	:	404-229-5201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2010
Last Update Date	:	02/12/2021

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