Healthcare Provider Details

I. General information

NPI: 1003328931
Provider Name (Legal Business Name): PATRICE L CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 S PORTAGE PATH
AKRON OH
44320-2326
US

IV. Provider business mailing address

380 S PORTAGE PATH
AKRON OH
44320-2326
US

V. Phone/Fax

Practice location:
  • Phone: 330-315-4109
  • Fax:
Mailing address:
  • Phone: 330-315-4109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: