Provider Demographics
NPI:1932282704
Name:CLARK, ROBERT LUCIEN (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LUCIEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LAKE PT
Mailing Address - Street 2:
Mailing Address - City:SAUTEE NACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571-5180
Mailing Address - Country:US
Mailing Address - Phone:706-878-1485
Mailing Address - Fax:
Practice Address - Street 1:42 NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1398
Practice Address - Country:US
Practice Address - Phone:706-348-8674
Practice Address - Fax:706-348-8676
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health