Provider Demographics
NPI:1609118975
Name:CLARK, KYLE AMBER (LCPC, DCC, NCC)
Entity Type:Individual
Prefix:MS
First Name:KYLE AMBER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCPC, DCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6198 CHRISTIAN KEMP DR N
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2718
Mailing Address - Country:US
Mailing Address - Phone:240-720-7307
Mailing Address - Fax:
Practice Address - Street 1:3059 S OGDEN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-1749
Practice Address - Country:US
Practice Address - Phone:720-642-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD123687101YM0800X
MDLC4454101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health