Provider Demographics
NPI:1386676419
Name:CLARK, ANGELA S (MA, LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMHC, LPC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:S
Other - Last Name:CLARK-HANIFY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMHC
Mailing Address - Street 1:2620 S PARKER RD
Mailing Address - Street 2:SUITE 272
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1608
Mailing Address - Country:US
Mailing Address - Phone:515-802-4837
Mailing Address - Fax:
Practice Address - Street 1:2620 S PARKER RD
Practice Address - Street 2:SUITE 272
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1608
Practice Address - Country:US
Practice Address - Phone:515-802-4837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01810101YM0800X
CO0012011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29021OtherWELLMARK BLUE SHIELD