Provider Demographics
NPI:1609104926
Name:CLARK, SHANDREA (LPC)
Entity Type:Individual
Prefix:
First Name:SHANDREA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 E WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JO
Mailing Address - State:TX
Mailing Address - Zip Code:76265-2189
Mailing Address - Country:US
Mailing Address - Phone:940-841-0779
Mailing Address - Fax:
Practice Address - Street 1:710 W WISE ST
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:TX
Practice Address - Zip Code:76230-4740
Practice Address - Country:US
Practice Address - Phone:940-841-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62851101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional