Provider Demographics
NPI:1003204702
Name:CLEAR LAKE STUDIO, LLC
Entity Type:Organization
Organization Name:CLEAR LAKE STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SKIRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-345-5489
Mailing Address - Street 1:1925 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-2027
Mailing Address - Country:US
Mailing Address - Phone:915-345-5489
Mailing Address - Fax:575-541-3690
Practice Address - Street 1:1925 ANITA DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2027
Practice Address - Country:US
Practice Address - Phone:915-345-5489
Practice Address - Fax:575-541-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0150641101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty