Provider Demographics
NPI:1619712429
Name:CLARK, DEBORAH JOY
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JOY
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:PO BOX 1594
Mailing Address - Street 2:
Mailing Address - City:WEST YELLOWSTONE
Mailing Address - State:MT
Mailing Address - Zip Code:59758-1594
Mailing Address - Country:US
Mailing Address - Phone:406-201-0657
Mailing Address - Fax:406-646-7754
Practice Address - Street 1:2265 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2996
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist