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General NPI Number Information
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NPI Number | 1033633037
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Entity Type | Individual
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Provider Name | MARISSA CLARK MS, CGC
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Gender | Female
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Dates
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Enumeration Date | 08/01/2017
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Last Update Date | 08/01/2017
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Provider Practice Location Address
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Address Line | 2827 FORT MISSOULA RD. SUITE 317
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City | MISSOULA
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State | MT
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Zip | 59804
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Country | US
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Telephone | 406-327-3924
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Fax | 406-327-3923
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Provider Business Mailing Address
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Address Line | 4804 HOBLITT LN S
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City | FLORENCE
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State | MT
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Zip | 59833-6832
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 170300000X
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Taxonomy Name | Genetic Counselor (M.S.)
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License Number |
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License Number State |
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