Individual
DR. MARYLYN ANN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH D
Contact information
Practice address
222 WEST GURLEY ST. SUITE 105, PRESCOTT, AZ 86301-3244
(928) 778-1806
(928) 541-9308
Mailing address
PO BOX 10246, PRESCOTT, PRESCOTT, AZ 86304-0246
(928) 778-1806
(928) 541-5308
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
LISAC11094
AZ
106H00000X
Marriage & Family Therapist
Primary
LMFT0053
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
EIN203600957
IRS
—
Enumeration date
01/25/2007
Last updated
07/02/2013
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