| NPI | 1578048062 |
|---|---|
| Former Name | EBONIE MARIE CLARK |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WA 61011133) |
| Enumeration Date | 2018-10-01 |
| Last Update Date | 2021-10-18 |