Provider Demographics
NPI:1912387127
Name:CLARK, RHONDA
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-7732
Mailing Address - Country:US
Mailing Address - Phone:606-886-9989
Mailing Address - Fax:
Practice Address - Street 1:207 W COURT ST
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-7732
Practice Address - Country:US
Practice Address - Phone:606-886-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY810154101YA0400X
KY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No291U00000XLaboratoriesClinical Medical Laboratory