Provider Demographics
NPI:1174023980
Name:CLARK, STACINA ELIZABETH (LPC)
Entity Type:Individual
Prefix:MRS
First Name:STACINA
Middle Name:ELIZABETH
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 1:222 BLANCHARD RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2807
Mailing Address - Country:US
Mailing Address - Phone:215-284-8500
Mailing Address - Fax:
Practice Address - Street 1:2000 OLD WEST CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2712
Practice Address - Country:US
Practice Address - Phone:484-454-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health