Provider Demographics
NPI:1154583268
Name:CLARK, TAMMY EVETTE (LPC)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:EVETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 PUTTER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3806
Mailing Address - Country:US
Mailing Address - Phone:314-994-9466
Mailing Address - Fax:
Practice Address - Street 1:1133 PUTTER LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3806
Practice Address - Country:US
Practice Address - Phone:314-994-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008011148101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional