Provider Demographics
NPI:1407195183
Name:CLARK, MADISON ANNE (LPC CANDIDATE)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4403
Mailing Address - Country:US
Mailing Address - Phone:405-882-4960
Mailing Address - Fax:
Practice Address - Street 1:711 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6918
Practice Address - Country:US
Practice Address - Phone:405-882-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1407195183Medicaid