Provider Demographics
NPI:1104343995
Name:CLARK, STEPHANIE (LMFT, LPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SADDLE HILL CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:770-674-1820
Mailing Address - Fax:
Practice Address - Street 1:1175 CANTON ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3692
Practice Address - Country:US
Practice Address - Phone:404-394-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006348101YP2500X
GA001264106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional