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General NPI Number Information
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NPI Number | 1568949923
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Entity Type | Organization
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Legal Business Name | MARIA CLARK LLC
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Dates
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Enumeration Date | 07/27/2018
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Last Update Date | 07/27/2018
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Provider Practice Location Address
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Address Line | 1620 WILSHIRE DR STE 222
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City | BELLEVUE
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State | NE
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Zip | 68005-6600
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Country | US
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Telephone | 402-536-9568
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Fax | 402-905-4767
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Provider Business Mailing Address
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Address Line | 2613 BLACKHAWK DR
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City | BELLEVUE
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State | NE
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Zip | 68123-3707
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Country | US
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Telephone | 402-536-9568
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Fax | 402-905-4767
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Authorized Official
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Title or Position | LIMHP
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Name | MARIA CLARK
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Credential | MS
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Telephone | 402-536-9568
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1579
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1579
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License Number State | NE
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