Provider Demographics
NPI:1760765374
Name:CLARK, VICKIE DIANE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10905 NW 10TH ST.
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74344
Mailing Address - Country:US
Mailing Address - Phone:918-791-1995
Mailing Address - Fax:405-769-7572
Practice Address - Street 1:10905 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-2209
Practice Address - Country:US
Practice Address - Phone:918-791-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor