Provider Demographics
NPI:1487163002
Name:CLARK, SCOTT THOMAS (LPCC)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 GOLD AVE SW STE 1F
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3119
Mailing Address - Country:US
Mailing Address - Phone:505-596-0614
Mailing Address - Fax:
Practice Address - Street 1:609 GOLD AVE SW STE 1F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3119
Practice Address - Country:US
Practice Address - Phone:505-758-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0217051101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04123751Medicaid