Provider Demographics
NPI:1215147400
Name:GUEST, CLARK WILLIAM (LAADC #LNR2090411)
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:WILLIAM
Last Name:GUEST
Suffix:
Gender:M
Credentials:LAADC #LNR2090411
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W IRONWOOD DR # D-104
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1403
Mailing Address - Country:US
Mailing Address - Phone:208-449-2509
Mailing Address - Fax:
Practice Address - Street 1:9494 N GOVERNMENT WAY # 202
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9848
Practice Address - Country:US
Practice Address - Phone:208-449-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA051235101YA0400X
106H00000X
ID7590101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist