Provider Demographics
NPI:1952435406
Name:CLARK, STEVEN A (CACIII)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 EDGEMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2345
Mailing Address - Country:US
Mailing Address - Phone:719-589-4090
Mailing Address - Fax:
Practice Address - Street 1:8745 COUNTY ROAD 9 S
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-9610
Practice Address - Country:US
Practice Address - Phone:719-589-3671
Practice Address - Fax:719-587-5693
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1851101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1851OtherCACIII