Provider Demographics
NPI:1114777653
Name:CLARK, JOSEPH (TCADC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7772
Mailing Address - Country:US
Mailing Address - Phone:502-762-8488
Mailing Address - Fax:
Practice Address - Street 1:130 HOPE ST
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7772
Practice Address - Country:US
Practice Address - Phone:502-904-9217
Practice Address - Fax:502-904-0856
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)