Provider Demographics
NPI:1902022999
Name:CLARK, ANNETTE R (LPCC)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:R
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 1:123 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43624-1107
Mailing Address - Country:US
Mailing Address - Phone:419-241-6191
Mailing Address - Fax:419-255-5623
Practice Address - Street 1:123 22ND ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43624-1107
Practice Address - Country:US
Practice Address - Phone:419-241-6191
Practice Address - Fax:419-255-5623
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE 0003343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional