Provider Demographics
NPI:1932577459
Name:RANDY CLARK LPC LLC
Entity Type:Organization
Organization Name:RANDY CLARK LPC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC LCADC
Authorized Official - Phone:973-220-9864
Mailing Address - Street 1:209 COOPER AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1850
Mailing Address - Country:US
Mailing Address - Phone:973-220-9864
Mailing Address - Fax:973-807-9363
Practice Address - Street 1:209 COOPER AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1850
Practice Address - Country:US
Practice Address - Phone:973-220-9864
Practice Address - Fax:973-807-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health