MEDICARE: DR. LISA CLARK PH.D.

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	103TC0700X	Clinical Psychologist	PSY002509	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952378226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA CLARK PH.D.

Provider Business Mailing Address
First Line	:	4557 MEADOW CREEK PATH
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-7704
Country	:	US
Telephone Number	:	678-519-1038
Fax Number	:	770-756-9195

Provider Business Practice Location Address
First Line	:	225 MEDICAL WAY
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2522
Country	:	US
Telephone Number	:	678-519-1038
Fax Number	:	770-756-9195

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

Provider Enumeration Date	:	03/04/2006
Last Update Date	:	02/10/2011

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Directions to “ DR. LISA CLARK PH.D.” Practice Location

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