Provider Demographics
NPI:1205913191
Name:CLARK, CONNIE LYNN (MSED, LCPC)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 S DURKIN DR
Mailing Address - Street 2:STE. B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1370
Mailing Address - Country:US
Mailing Address - Phone:217-753-1288
Mailing Address - Fax:
Practice Address - Street 1:955 S DURKIN DR
Practice Address - Street 2:STE. B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1370
Practice Address - Country:US
Practice Address - Phone:217-753-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006792101YP2500X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor