Provider Demographics
NPI:1932243292
Name:CLACK, LESLEY A (LPC)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:A
Last Name:CLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 TIFTON ELDORADO RD
Mailing Address - Street 2:P. O. BOX 1448
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-9497
Mailing Address - Country:US
Mailing Address - Phone:229-386-3494
Mailing Address - Fax:229-386-3221
Practice Address - Street 1:334 TIFTON ELDORADO RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-9497
Practice Address - Country:US
Practice Address - Phone:229-386-3494
Practice Address - Fax:229-386-3221
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALAPC1190101YP2500X
GALPC005021101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional