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General NPI Number Information
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NPI Number | 1922116508
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Entity Type | Individual
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Provider Name | LILLEE CLARK PH.D.
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Gender | Female
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 03/02/2010
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Provider Practice Location Address
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Address Line | 605 GREEN ST NW STE B
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City | GAINESVILLE
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State | GA
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Zip | 30501-3319
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Country | US
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Telephone | 770-538-4800
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Fax | 770-503-9299
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Provider Business Mailing Address
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Address Line | 605 GREEN ST NW STE B
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City | GAINESVILLE
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State | GA
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Zip | 30501-3319
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Country | US
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Telephone | 770-538-4800
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Fax | 770-503-9299
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 001290
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License Number State | GA
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