Provider Demographics
NPI:1073531125
Name:CLARK, JOAN MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-0826
Mailing Address - Country:US
Mailing Address - Phone:888-760-1996
Mailing Address - Fax:979-776-4804
Practice Address - Street 1:2402 BROADMOOR DR
Practice Address - Street 2:101-C
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2847
Practice Address - Country:US
Practice Address - Phone:979-774-4134
Practice Address - Fax:979-776-4804
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional