Provider Demographics
NPI:1306015284
Name:CLARK, SANDRA LOUISE (NCACII, LADC, CCJP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NCACII, LADC, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3489
Mailing Address - Country:US
Mailing Address - Phone:651-373-0152
Mailing Address - Fax:763-767-3145
Practice Address - Street 1:1885 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 20
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3489
Practice Address - Country:US
Practice Address - Phone:651-373-0152
Practice Address - Fax:763-767-3145
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301712101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)