Provider Demographics
NPI:1891192688
Name:CLARK, LINDA (LADC/MH CANDIDATE)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LADC/MH CANDIDATE
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:CLARK
Other - Last Name:RIDENOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20433
Mailing Address - Street 2:PO BOX 20433
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73156-0433
Mailing Address - Country:US
Mailing Address - Phone:405-748-0789
Mailing Address - Fax:
Practice Address - Street 1:16301 SONOMA PARK DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2091
Practice Address - Country:US
Practice Address - Phone:405-748-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-23
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76101YA0400X
OKOCC-05967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist