Provider Demographics
NPI:1528583408
Name:CLARK, MONICA KAYE (LPA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9720 PARK PLAZA AVE UNIT 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2289
Practice Address - Country:US
Practice Address - Phone:502-339-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical