Provider Demographics
NPI:1619614195
Name:CLARK, CRYSTAL (PHD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S CARROLL BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-7423
Mailing Address - Country:US
Mailing Address - Phone:940-553-0012
Mailing Address - Fax:469-613-0883
Practice Address - Street 1:501 S CARROLL BLVD STE 230
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-7423
Practice Address - Country:US
Practice Address - Phone:940-553-0012
Practice Address - Fax:469-613-0883
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
79203OtherLICENSE - LPC