Provider Demographics
NPI:1497534044
Name:CLARK, AMY ELIZABETH (MS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 S 96TH ST STE 222
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-1243
Mailing Address - Country:US
Mailing Address - Phone:402-616-5139
Mailing Address - Fax:
Practice Address - Street 1:4611 S 96TH ST STE 222
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1243
Practice Address - Country:US
Practice Address - Phone:402-616-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13147101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health