Provider Demographics
NPI:1912022484
Name:CLARK, GARY MIKE (LMFT)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MIKE
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8014 RED BUD HILL DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-2215
Mailing Address - Country:US
Mailing Address - Phone:502-523-5433
Mailing Address - Fax:502-239-1651
Practice Address - Street 1:8911 3RD STREET RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-2501
Practice Address - Country:US
Practice Address - Phone:502-523-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0272106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist