Provider Demographics
NPI:1427549864
Name:CLARK, OLIVIA (LPC, BCN)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC, BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PORTAGE TRL
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-2109
Mailing Address - Country:US
Mailing Address - Phone:330-227-8223
Mailing Address - Fax:
Practice Address - Street 1:1600 PORTAGE TRL
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-2109
Practice Address - Country:US
Practice Address - Phone:330-227-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002860101YM0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health