Provider Demographics
NPI:1093387656
Name:CLARK, DEVIN WESLEY (LPC-A)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:WESLEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 RIVERSIDE DRIVE
Mailing Address - Street 2:BUILDING 6, SUITE 100E
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039
Mailing Address - Country:US
Mailing Address - Phone:510-858-6775
Mailing Address - Fax:
Practice Address - Street 1:5000 RIVERSIDE DRIVE
Practice Address - Street 2:BUILDING 6, SUITE 100E
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039
Practice Address - Country:US
Practice Address - Phone:510-858-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82927OtherLPC-A