Provider Demographics
NPI:1063939817
Name:CLARK, RANDY GENE SR
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:GENE
Last Name:CLARK
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45335 SIERRA HWY
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-1611
Mailing Address - Country:US
Mailing Address - Phone:661-949-8599
Mailing Address - Fax:
Practice Address - Street 1:1639 BRUCE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-7691
Practice Address - Country:US
Practice Address - Phone:417-308-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO202404464101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional