Provider Demographics
NPI:1760824569
Name:CLARK, CHRISTINE (LPC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
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:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:3111 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1610161101YP2500X
ARA1402025101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional