Provider Demographics
NPI:1114595246
Name:CLARK, LATRECE
Entity type:Individual
Prefix:
First Name:LATRECE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATRECE
Other - Middle Name:
Other - Last Name:FERGUSON-CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6043 W INTERSTATE 20
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1042
Mailing Address - Country:US
Mailing Address - Phone:817-533-0825
Mailing Address - Fax:817-953-8899
Practice Address - Street 1:6043 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1042
Practice Address - Country:US
Practice Address - Phone:817-533-0825
Practice Address - Fax:817-953-8899
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70305103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist