Provider Demographics
NPI:1144761099
Name:CLARK, REBECCA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
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 1:1981 N MCRAE CT
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-8579
Mailing Address - Country:US
Mailing Address - Phone:316-347-5946
Mailing Address - Fax:
Practice Address - Street 1:24401 W 39TH ST S
Practice Address - Street 2:
Practice Address - City:GODDARD
Practice Address - State:KS
Practice Address - Zip Code:67052-8713
Practice Address - Country:US
Practice Address - Phone:316-794-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional