Provider Demographics
NPI:1841172640
Name:CLARK, STELLA LEIGH
Entity type:Individual
Prefix:MISS
First Name:STELLA
Middle Name:LEIGH
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 1:1557 BUFORD DR # 491913
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3718
Mailing Address - Country:US
Mailing Address - Phone:501-570-6378
Mailing Address - Fax:
Practice Address - Street 1:1557 BUFORD DR # 491913
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3718
Practice Address - Country:US
Practice Address - Phone:501-570-6378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician