Provider Demographics
NPI:1740975846
Name:CLARK, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 1:16016 233RD ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-5583
Mailing Address - Country:US
Mailing Address - Phone:320-632-5524
Mailing Address - Fax:888-991-2741
Practice Address - Street 1:16016 233RD ST
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-5583
Practice Address - Country:US
Practice Address - Phone:320-632-5524
Practice Address - Fax:888-991-2741
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional