Provider Demographics
NPI:1215085600
Name:CLARK, LEONARD A (LCSW)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W LOWRY LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3019
Mailing Address - Country:US
Mailing Address - Phone:859-229-8160
Mailing Address - Fax:859-276-5206
Practice Address - Street 1:200 W LOWRY LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3019
Practice Address - Country:US
Practice Address - Phone:859-229-8160
Practice Address - Fax:859-276-5206
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYADCLAD0022409101YA0400X
KY1498104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0575123Medicare ID - Type UnspecifiedMEDICARE
KY30615058Medicaid