Provider Demographics
NPI:1255144507
Name:CLARK, SELENA NICOLE CHRISTINE (ALC)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:NICOLE CHRISTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 KILPATRICK LN NW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35058-1856
Mailing Address - Country:US
Mailing Address - Phone:256-706-9855
Mailing Address - Fax:
Practice Address - Street 1:623 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4136
Practice Address - Country:US
Practice Address - Phone:256-673-4346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALACC05193101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor