Provider Demographics
NPI:1568185353
Name:CLARK, AMANDA (LAC, NCC, BHP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC, NCC, BHP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:KLEMENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9895 E ASTER DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-4635
Mailing Address - Country:US
Mailing Address - Phone:480-227-0219
Mailing Address - Fax:
Practice Address - Street 1:6125 E INDIAN SCHOOL RD STE 1005
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5469
Practice Address - Country:US
Practice Address - Phone:623-570-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20338101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health