Provider Demographics
NPI:1467893032
Name:CLARK, NICOLE LANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0314
Mailing Address - Country:US
Mailing Address - Phone:530-209-5545
Mailing Address - Fax:
Practice Address - Street 1:31292 ALPINE MEADOWS RD
Practice Address - Street 2:
Practice Address - City:SHINGLETOWN
Practice Address - State:CA
Practice Address - Zip Code:96088-9462
Practice Address - Country:US
Practice Address - Phone:530-474-3390
Practice Address - Fax:530-474-1407
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91794101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL