Provider Demographics
NPI:1962004887
Name:CLARK, KIRBY KAY LAJETT (MPC)
Entity Type:Individual
Prefix:
First Name:KIRBY KAY
Middle Name:LAJETT
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2452 ROUTE 9, SUITE 302
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:316-706-3275
Mailing Address - Fax:
Practice Address - Street 1:76 SPRINGWOOD MEADOWS DR
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3541
Practice Address - Country:US
Practice Address - Phone:316-706-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP104773101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health