Provider Demographics
NPI:1194541631
Name:CLARK, SANDRA (LPC ASSOCIATE)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3337
Mailing Address - Country:US
Mailing Address - Phone:646-243-8263
Mailing Address - Fax:
Practice Address - Street 1:2709 MAY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-3337
Practice Address - Country:US
Practice Address - Phone:646-243-8263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX95242101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional