Provider Demographics
NPI:1013194000
Name:CLARK, LAURETTA E
Entity Type:Individual
Prefix:
First Name:LAURETTA
Middle Name:E
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 1:4068 E PECOS RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2529
Mailing Address - Country:US
Mailing Address - Phone:480-279-7321
Mailing Address - Fax:480-279-7305
Practice Address - Street 1:4068 E PECOS RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-2529
Practice Address - Country:US
Practice Address - Phone:480-279-7321
Practice Address - Fax:480-279-7305
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool