Provider Demographics
NPI:1508184946
Name:CLARK, ADELINE (LPC-S)
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 SUSANA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8736
Mailing Address - Country:US
Mailing Address - Phone:443-621-2835
Mailing Address - Fax:
Practice Address - Street 1:207 SUSANA DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8736
Practice Address - Country:US
Practice Address - Phone:443-621-2835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPCS70788101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD816700100Medicaid