Provider Demographics
NPI:1104187814
Name:CLARK, KAYLEIGH (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E A ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2252
Mailing Address - Country:US
Mailing Address - Phone:307-235-3333
Mailing Address - Fax:307-266-5155
Practice Address - Street 1:1300 E A ST STE 201
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2252
Practice Address - Country:US
Practice Address - Phone:307-235-3333
Practice Address - Fax:307-266-5155
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical