Basic Information
| Provider Information | |||||||||
| NPI: | 1699026773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PH.D, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5415 SUGARLOAF PKWY STE 1108 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300437832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705352545 | ||||||||
| FaxNumber: | 2707451156 | ||||||||
| Practice Location | |||||||||
| Address1: | 5415 SUGARLOAF PKWY STE 1108 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300437832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705352545 | ||||||||
| FaxNumber: | 2707451156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW007735 | GA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 1151-3714C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.