Provider Demographics
NPI:1588854236
Name:CLARK, WILLIAM RANDOLPH (LPC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12880 HILLCREST RD
Mailing Address - Street 2:J-235
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1532
Mailing Address - Country:US
Mailing Address - Phone:214-729-9396
Mailing Address - Fax:972-385-0711
Practice Address - Street 1:12880 HILLCREST RD
Practice Address - Street 2:J-235
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1532
Practice Address - Country:US
Practice Address - Phone:214-729-9396
Practice Address - Fax:972-385-0711
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61784101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor