Provider Demographics
NPI:1497092704
Name:CLARK, LESLIE A (LPC, CSAC, CIR, ICS-)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC, CSAC, CIR, ICS-
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11011 W. NORTH AVE.
Mailing Address - Street 2:APT.309
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-367-6698
Mailing Address - Fax:
Practice Address - Street 1:7071 S. 13TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154
Practice Address - Country:US
Practice Address - Phone:414-367-6698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16215-132101YM0800X
WI1180-226104100000X
WI5204-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027595Medicaid