Provider Demographics
NPI:1831112671
Name:CLARK, REBECCA JAND (LPCC, CRC)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:JAND
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPCC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CALLE DEL PINON
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-9691
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:505-256-2819
Practice Address - Street 1:1501 SAN PEDRO SE (116)
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE,
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-2819
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0077551101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional