Provider Demographics
NPI:1598438715
Name:CLARK, DEBORAH LEE (MS, LPC, CCTP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LPC, CCTP
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:LEE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC, CCTP
Mailing Address - Street 1:48 24 3/4 AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-8817
Mailing Address - Country:US
Mailing Address - Phone:715-281-5341
Mailing Address - Fax:
Practice Address - Street 1:48 24 3/4 AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-8817
Practice Address - Country:US
Practice Address - Phone:715-281-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6633-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health