MEDICARE: MONIQUE ALTERISS CLARK QMHP

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	101YM0800X	Mental Health Counselor	0733004653	VA

General Provider Information

NPI Number	:	1760184303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIQUE ALTERISS CLARK QMHP

Provider Business Mailing Address
First Line	:	3707 PENNYWEIGHT CT
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-1977
Country	:	US
Telephone Number	:	804-955-7134
Fax Number	:

Provider Business Practice Location Address
First Line	:	132 N SYCAMORE ST # 27
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3262
Country	:	US
Telephone Number	:	804-955-7332
Fax Number	:

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

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	03/20/2023

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