Provider Demographics
NPI:1285254672
Name:CLARK, KATHERINE AUDREY (MA, LMHC, NCC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:AUDREY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 HENDERSON BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3970
Mailing Address - Country:US
Mailing Address - Phone:727-537-0752
Mailing Address - Fax:
Practice Address - Street 1:3502 HENDERSON BLVD STE 218
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3970
Practice Address - Country:US
Practice Address - Phone:727-537-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17084101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health