Provider Demographics
NPI:1154608503
Name:CLARK, CHRISTY LYNN (MA LPC)
Entity type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 LEE HILL RD
Mailing Address - Street 2:#7
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0877
Mailing Address - Country:US
Mailing Address - Phone:303-578-8871
Mailing Address - Fax:
Practice Address - Street 1:3978 ARBOL CT
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1752
Practice Address - Country:US
Practice Address - Phone:303-578-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC-5772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health