Provider Demographics
NPI:1023185519
Name:CLARK, TERESA WATKINS (LPCC)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:WATKINS
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-9091
Mailing Address - Country:US
Mailing Address - Phone:505-281-7419
Mailing Address - Fax:
Practice Address - Street 1:1330 SAN PEDRO DR NE
Practice Address - Street 2:SUITE 201B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6744
Practice Address - Country:US
Practice Address - Phone:505-260-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0874101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional