Provider Demographics
NPI:1396234225
Name:CLARK, KYNDLE RENEE (LPC , CDCA)
Entity type:Individual
Prefix:
First Name:KYNDLE
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC , CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1208
Mailing Address - Country:US
Mailing Address - Phone:740-477-1745
Mailing Address - Fax:
Practice Address - Street 1:110 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1208
Practice Address - Country:US
Practice Address - Phone:740-477-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health