Provider Demographics
NPI:1275722365
Name:CLARK, DAVID ALLAN (LADC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALLAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50196 872ND RD
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:NE
Mailing Address - Zip Code:68766-5539
Mailing Address - Country:US
Mailing Address - Phone:402-338-5510
Mailing Address - Fax:402-338-5510
Practice Address - Street 1:50196 872ND RD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:NE
Practice Address - Zip Code:68766-5539
Practice Address - Country:US
Practice Address - Phone:402-338-5510
Practice Address - Fax:402-338-5510
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE594101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)