Provider Demographics
NPI:1013425578
Name:CLARK, ANGELA JOHAN (LPC, LPCC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:JOHAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 SWEETWATER SPRINGS BLVD APT 78
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91978-1530
Mailing Address - Country:US
Mailing Address - Phone:816-548-7673
Mailing Address - Fax:
Practice Address - Street 1:673 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7576
Practice Address - Country:US
Practice Address - Phone:530-913-7221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017043804101YP2500X
CA13646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional