Provider Demographics
NPI:1154196665
Name:CLARK, DORTHEA A (MA IN MENTAL HEALTH)
Entity type:Individual
Prefix:
First Name:DORTHEA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA IN MENTAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-631-7381
Mailing Address - Fax:
Practice Address - Street 1:4025 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1900
Practice Address - Country:US
Practice Address - Phone:307-426-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1416101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty