Provider Demographics
NPI:1366689895
Name:CLARK, LISA F (LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:F
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPCC
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 1150
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-5150
Mailing Address - Country:US
Mailing Address - Phone:606-546-9287
Mailing Address - Fax:606-546-0009
Practice Address - Street 1:140 BRYAN BLVD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2775
Practice Address - Country:US
Practice Address - Phone:606-523-2005
Practice Address - Fax:606-523-9704
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY247004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100128550Medicaid
KY7100128550Medicaid