Provider Demographics
NPI:1154795276
Name:CLARK, GLORIA (LMHC)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S DUNCAN DR
Mailing Address - Street 2:BUILDING E
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4223
Mailing Address - Country:US
Mailing Address - Phone:352-343-0752
Mailing Address - Fax:352-315-7587
Practice Address - Street 1:1300 S DUNCAN DR
Practice Address - Street 2:BUILDING E
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4223
Practice Address - Country:US
Practice Address - Phone:352-343-0752
Practice Address - Fax:352-315-7587
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13844101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor