Provider Demographics
NPI:1821484494
Name:CLARK, LECRETIA WILLIAMS (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:LECRETIA
Middle Name:WILLIAMS
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-5072
Mailing Address - Country:US
Mailing Address - Phone:662-286-9883
Mailing Address - Fax:662-284-9836
Practice Address - Street 1:2705 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2634
Practice Address - Country:US
Practice Address - Phone:662-449-1971
Practice Address - Fax:662-449-1974
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3389101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health