Provider Demographics
NPI:1265742001
Name:CLARK, SAMUEL P (LMH)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:LMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16243 SW 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-4778
Mailing Address - Country:US
Mailing Address - Phone:352-244-0628
Mailing Address - Fax:352-334-3817
Practice Address - Street 1:1218 NW 6TH STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601
Practice Address - Country:UM
Practice Address - Phone:352-244-0628
Practice Address - Fax:352-334-3817
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH820101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)