Provider Demographics
NPI:1902114762
Name:CLARK, LISA S
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 HIGHWAY 36 W
Mailing Address - Street 2:
Mailing Address - City:ROSE BUD
Mailing Address - State:AR
Mailing Address - Zip Code:72137-9705
Mailing Address - Country:US
Mailing Address - Phone:866-533-1766
Mailing Address - Fax:
Practice Address - Street 1:931 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:ROSE BUD
Practice Address - State:AR
Practice Address - Zip Code:72137-9721
Practice Address - Country:US
Practice Address - Phone:866-533-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator