{
"Npi": {
"NPI": "1477044071",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "CLARK",
"FirstName": "SHANAVIER",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "10467 CORPORATE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GULFPORT",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "39503-4634",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "228-374-2494",
"MailingAddressFaxNumber": "228-396-3457",
"FirstLinePracticeLocationAddress": "15024 MARTIN LUTHER KING JR BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GULFPORT",
"PracticeLocationAddressStateName": "MS",
"PracticeLocationAddressPostalCode": "39501-8306",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "228-864-0003",
"PracticeLocationAddressFaxNumber": "228-863-7917",
"EnumerationDate": "05/21/2018",
"LastUpdateDate": "11/24/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YA0400X",
"TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "104100000X",
"TaxonomyName": "Social Worker",
"LicenseNumber": "C11808",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}