Provider Demographics
NPI:1417638800
Name:KELLY-CLARK, ANTOINETTE
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:
Last Name:KELLY-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 1:171 WATER TANK RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-8550
Mailing Address - Country:US
Mailing Address - Phone:318-548-7242
Mailing Address - Fax:
Practice Address - Street 1:171 WATER TANK RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8550
Practice Address - Country:US
Practice Address - Phone:318-548-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling