Basic Information
| Provider Information | |||||||||
| NPI: | 1073931085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.ED. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 HORIZON DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815068743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 OURAY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702416099 | ||||||||
| FaxNumber: | 9702410797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.