Provider Demographics
NPI:1760495329
Name:CLARK, ALICE M (MA, LPC, CACIII)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LPC, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 YAUPON AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4364
Mailing Address - Country:US
Mailing Address - Phone:303-263-7855
Mailing Address - Fax:
Practice Address - Street 1:5377 MANHATTAN CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4333
Practice Address - Country:US
Practice Address - Phone:303-263-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5499101YA0400X
CO1687101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)