Provider Demographics
NPI:1922299122
Name:CLARK, ANNE (LPCC)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
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 1:1115 N SHOOP AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1857
Mailing Address - Country:US
Mailing Address - Phone:419-335-6122
Mailing Address - Fax:419-318-4157
Practice Address - Street 1:1115 N SHOOP AVE STE 1
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1857
Practice Address - Country:US
Practice Address - Phone:419-335-6122
Practice Address - Fax:419-318-4157
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE4140101YM0800X
OH031136101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)