MEDICARE: MARYLOU CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	60354	TX

General Provider Information

NPI Number	:	1093411670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYLOU CLARK

Provider Business Mailing Address
First Line	:	2415 CLIPPERS SQ
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3742
Country	:	US
Telephone Number	:	281-435-7428
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 CLIPPERS SQ
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3742
Country	:	US
Telephone Number	:	281-435-7428
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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Directions to “ MARYLOU CLARK ” Practice Location

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