Provider Demographics
NPI:1306001540
Name:CLARK, RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:RENEE
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 1:21055 175TH ST
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-5365
Mailing Address - Country:US
Mailing Address - Phone:913-682-5118
Mailing Address - Fax:913-682-4664
Practice Address - Street 1:500 LIMIT ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-4435
Practice Address - Country:US
Practice Address - Phone:913-682-5118
Practice Address - Fax:913-682-4664
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional