Provider Demographics
NPI:1427382043
Name:CLARK, GINNA (LPCC)
Entity Type:Individual
Prefix:
First Name:GINNA
Middle Name:
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 1:1344 PACHECO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4267
Mailing Address - Country:US
Mailing Address - Phone:505-316-0775
Mailing Address - Fax:972-736-2271
Practice Address - Street 1:1344 PACHECO ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4267
Practice Address - Country:US
Practice Address - Phone:505-316-0775
Practice Address - Fax:972-736-2271
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NM0140471101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health