Provider Demographics
NPI:1770995961
Name:CLARK, KIMBRLEY D (LICDC-CS)
Entity type:Individual
Prefix:
First Name:KIMBRLEY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41821 WHITNEY RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-9458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2057 S. AVON-BELDEN RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:OH
Practice Address - Zip Code:44044
Practice Address - Country:US
Practice Address - Phone:440-748-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121985101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)