Provider Demographics
NPI:1275791949
Name:CLARK, KATHERINE DIANE (LPC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:220 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2522
Mailing Address - Country:US
Mailing Address - Phone:719-572-6150
Mailing Address - Fax:
Practice Address - Street 1:400 W MIDLAND AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3144
Practice Address - Country:US
Practice Address - Phone:719-687-2880
Practice Address - Fax:719-686-0738
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1898101YP2500X
CO91681163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse