Provider Demographics
NPI:1740276906
Name:CLARK, KATHLEEN M (LCSW , BCD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW , BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3724 JEFFERSON ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6221
Mailing Address - Country:US
Mailing Address - Phone:512-452-8948
Mailing Address - Fax:512-452-0459
Practice Address - Street 1:3724 JEFFERSON ST
Practice Address - Street 2:SUITE 206
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6221
Practice Address - Country:US
Practice Address - Phone:512-452-8948
Practice Address - Fax:512-452-0459
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS032181041C0700X
TX32181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical