Provider Demographics
NPI:1801156997
Name:CLARK, LESLIE JOY (LMSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOY
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 LAKEWOOD DR STE 2
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2969
Mailing Address - Country:US
Mailing Address - Phone:254-399-9099
Mailing Address - Fax:254-388-8397
Practice Address - Street 1:4830 LAKEWOOD DR STE 2
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2969
Practice Address - Country:US
Practice Address - Phone:254-399-9099
Practice Address - Fax:254-388-8397
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50312104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker