Provider Demographics
NPI:1659017200
Name:CLARK, KELLY CHRISTINA (LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CHRISTINA
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 1:3116 STONEHENGE LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-5214
Mailing Address - Country:US
Mailing Address - Phone:214-412-7629
Mailing Address - Fax:
Practice Address - Street 1:200 S 14TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-3358
Practice Address - Country:US
Practice Address - Phone:214-412-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77082101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional