Provider Demographics
NPI:1295021608
Name:CLARK, REBECCA A (LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
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:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4871
Mailing Address - Fax:682-885-3936
Practice Address - Street 1:1525 S COOPER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-4105
Practice Address - Country:US
Practice Address - Phone:817-804-1100
Practice Address - Fax:817-299-8790
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942509963OtherGROUP NPI