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General NPI Number Information
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NPI Number | 1457102659
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Entity Type | Individual
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Provider Name | CHATIELA CLARK EDS
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Gender | Female
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Dates
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Enumeration Date | 03/27/2024
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Last Update Date | 03/27/2024
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Provider Practice Location Address
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Address Line | 120 S UNIVERSITY DR STE F
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City | PLANTATION
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State | FL
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Zip | 33324-3346
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Country | US
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Telephone | 954-559-2936
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Fax |
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Provider Business Mailing Address
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Address Line | 2601 N ROCK ISLAND RD APT 305
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City | MARGATE
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State | FL
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Zip | 33063-1226
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Country | US
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Telephone | 570-497-0522
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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 | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | SS1819
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License Number State | FL
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