Provider Demographics
NPI:1619586104
Name:CLARK, JUDY PATRICIA (MED LPC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:PATRICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 CANDLEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-1320
Mailing Address - Country:US
Mailing Address - Phone:214-228-8747
Mailing Address - Fax:
Practice Address - Street 1:2809 REGAL RD # 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6317
Practice Address - Country:US
Practice Address - Phone:214-228-8697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional