Provider Demographics
NPI:1215117387
Name:CLARK, MARCIA M (MSN,LCPC)
Entity type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN,LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 S MATTIS AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4861
Mailing Address - Country:US
Mailing Address - Phone:217-359-5041
Mailing Address - Fax:217-359-8096
Practice Address - Street 1:1207 S MATTIS AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-4861
Practice Address - Country:US
Practice Address - Phone:217-359-5041
Practice Address - Fax:217-359-8096
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)