Provider Demographics
NPI:1750122099
Name:CLARK, ERIN ELIZABETH ANN (LAC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:ELIZABETH ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 ROCK ST
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-3403
Mailing Address - Country:US
Mailing Address - Phone:479-477-0739
Mailing Address - Fax:
Practice Address - Street 1:1157 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-9158
Practice Address - Country:US
Practice Address - Phone:479-705-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2402001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health