Provider Demographics
NPI:1003466947
Name:CLARK, EVA-SOPHIA (MA, LCSW, LCDC, EMDR)
Entity type:Individual
Prefix:MS
First Name:EVA-SOPHIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LCSW, LCDC, EMDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 N BEACH ST STE 114
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4245
Mailing Address - Country:US
Mailing Address - Phone:682-299-9406
Mailing Address - Fax:
Practice Address - Street 1:501 S CARROLL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-7423
Practice Address - Country:US
Practice Address - Phone:682-299-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66542104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker