Provider Demographics
NPI:1790561520
Name:CLARK, CHERYL (LMSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MCGUGAN LN
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3541
Mailing Address - Country:US
Mailing Address - Phone:254-541-6594
Mailing Address - Fax:
Practice Address - Street 1:5931 CROSSLAKE PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6986
Practice Address - Country:US
Practice Address - Phone:254-870-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106751101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health