Provider Demographics
NPI:1417297680
Name:CLARK, LAVINA KAY
Entity Type:Individual
Prefix:MRS
First Name:LAVINA
Middle Name:KAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 BAYLISS AVE
Mailing Address - Street 2:
Mailing Address - City:PAWHUSKA
Mailing Address - State:OK
Mailing Address - Zip Code:74056-9442
Mailing Address - Country:US
Mailing Address - Phone:918-287-5425
Mailing Address - Fax:918-287-1096
Practice Address - Street 1:126 E 6TH ST
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-4204
Practice Address - Country:US
Practice Address - Phone:918-287-5425
Practice Address - Fax:918-287-1096
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility