Healthcare Provider Details

I. General information

NPI: 1477044071
Provider Name (Legal Business Name): SHANAVIER CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15024 MARTIN LUTHER KING JR BLVD
GULFPORT MS
39501-8306
US

IV. Provider business mailing address

10467 CORPORATE DR
GULFPORT MS
39503-4634
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-0003
  • Fax: 228-863-7917
Mailing address:
  • Phone: 228-374-2494
  • Fax: 228-396-3457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC11808
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: