Provider Demographics
NPI:1982611463
Name:CLARK, STEPHANIE M (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E ROBERT ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-3350
Mailing Address - Country:US
Mailing Address - Phone:985-543-4070
Mailing Address - Fax:985-543-4073
Practice Address - Street 1:202 E ROBERT ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3350
Practice Address - Country:US
Practice Address - Phone:985-543-4070
Practice Address - Fax:985-543-4073
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA797101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)