Provider Demographics
NPI:1043570732
Name:CLARK, EDWARD (LPC, CCADC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC, CCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 NINE MCFARLAND DR
Mailing Address - Street 2:SUITE #175
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-8493
Mailing Address - Country:US
Mailing Address - Phone:678-982-9039
Mailing Address - Fax:470-235-8705
Practice Address - Street 1:4015 NINE MCFARLAND DR
Practice Address - Street 2:SUITE #175
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-8493
Practice Address - Country:US
Practice Address - Phone:678-982-9039
Practice Address - Fax:470-235-8705
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst