Provider Demographics
NPI:1477608867
Name:CLARK, LAURA KATHLEEN
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KATHLEEN
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 1:3464 SPUR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-8750
Mailing Address - Country:US
Mailing Address - Phone:540-951-2872
Mailing Address - Fax:
Practice Address - Street 1:305 WASHINGTON ST SW
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4745
Practice Address - Country:US
Practice Address - Phone:540-552-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001506103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7755023Medicaid