Healthcare Provider Details

I. General information

NPI: 1538077482
Provider Name (Legal Business Name): TATIANA MARIE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MARGIE DR
WARNER ROBINS GA
31088-7818
US

IV. Provider business mailing address

800 GUNN RD APT 332
CENTERVILLE GA
31028-8566
US

V. Phone/Fax

Practice location:
  • Phone: 404-224-9346
  • Fax:
Mailing address:
  • Phone: 228-437-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number26-538326
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: