Provider Demographics
NPI:1598776445
Name:CLARK, PEGGY J (LMFT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 1/2 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-1402
Mailing Address - Country:US
Mailing Address - Phone:515-432-6699
Mailing Address - Fax:515-432-5544
Practice Address - Street 1:823 KEELER ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-2729
Practice Address - Country:US
Practice Address - Phone:515-433-2100
Practice Address - Fax:515-432-5544
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAAPPLIEDMedicaid