Provider Demographics
NPI:1750399093
Name:CLARK, CARLA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 LEGACY LOOP
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4661
Mailing Address - Country:US
Mailing Address - Phone:318-487-4773
Mailing Address - Fax:
Practice Address - Street 1:1907 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3627
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:318-483-5064
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical