Provider Demographics
NPI:1861253965
Name:CLARK, ELYSSIA MAE (DC)
Entity type:Individual
Prefix:DR
First Name:ELYSSIA
Middle Name:MAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 JEFFCO BLVD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2719
Mailing Address - Country:US
Mailing Address - Phone:636-296-8123
Mailing Address - Fax:636-296-1900
Practice Address - Street 1:1804 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2719
Practice Address - Country:US
Practice Address - Phone:636-296-8123
Practice Address - Fax:636-296-1900
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023050836111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor