Provider Demographics
NPI:1740894955
Name:CLARK, LINDSEY RICHELLE
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:RICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COUNTY ROAD 191
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8677
Mailing Address - Country:US
Mailing Address - Phone:901-584-8281
Mailing Address - Fax:
Practice Address - Street 1:3720 ALUMNI AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-5914
Practice Address - Country:US
Practice Address - Phone:901-584-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-18-63131106S00000X
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician