Provider Demographics
NPI:1790001808
Name:CLARK, ELIZABETH KIMEN (LPCC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:KIMEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 FARMINGTON AVE SUITE B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4507
Mailing Address - Country:US
Mailing Address - Phone:505-324-0040
Mailing Address - Fax:505-324-0039
Practice Address - Street 1:2600 FARMINGTON AVE SUITE B
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4507
Practice Address - Country:US
Practice Address - Phone:505-324-0040
Practice Address - Fax:505-324-0039
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC2415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12507717Medicaid