Provider Demographics
NPI:1457725095
Name:CLARK, KAITLYN MARY (LPC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARY
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:MARY
Other - Last Name:BARTFAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3760 LAVISTA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5622
Mailing Address - Country:US
Mailing Address - Phone:770-375-8124
Mailing Address - Fax:770-559-5543
Practice Address - Street 1:3760 LAVISTA RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5622
Practice Address - Country:US
Practice Address - Phone:770-375-8124
Practice Address - Fax:770-559-5543
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
GALPC012288101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator