Healthcare Provider Details

I. General information

NPI: 1013812114
Provider Name (Legal Business Name): MRS. STEPHANIE BARBARA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 S JOG RD STE 303
DELRAY BEACH FL
33446-1249
US

IV. Provider business mailing address

331 HICKORY HOLLOW DR N
JACKSONVILLE FL
32225-3057
US

V. Phone/Fax

Practice location:
  • Phone: 561-503-3059
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: