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General NPI Number Information
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NPI Number | 1801022413
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Entity Type | Organization
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Legal Business Name | LISA CLARK ENTERPRISES, INC
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Dates
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Enumeration Date | 06/09/2009
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Last Update Date | 02/26/2018
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Provider Practice Location Address
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Address Line | 2785 LAWRENCEVILLE HWY STE 207
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City | DECATUR
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State | GA
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Zip | 30033-2515
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Country | US
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Telephone | 678-519-1038
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Fax | 678-239-4720
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Provider Business Mailing Address
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Address Line | 2309 NORBURY CV SE
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City | SMYRNA
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State | GA
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Zip | 30080-5206
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Country | US
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Telephone | 678-519-1038
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Fax | 678-239-4720
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Authorized Official
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Title or Position | CEO/PRESIDENT/OWNER
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Name | DR. LISA CLARK
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Credential | PH.D.
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Telephone | 404-276-3037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY002509
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License Number State | GA
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