Provider Demographics
NPI:1518590660
Name:CLARK, COURTNEY A (LAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PEARSON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4436
Mailing Address - Country:US
Mailing Address - Phone:501-315-4224
Mailing Address - Fax:501-778-0450
Practice Address - Street 1:110 PEARSON
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4436
Practice Address - Country:US
Practice Address - Phone:501-315-4224
Practice Address - Fax:501-778-0450
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2002030101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty