Provider Demographics
NPI:1588786529
Name:CLARK, JOHN RANDOLPH (LPC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RANDOLPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 HERNDON DR
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8539
Mailing Address - Country:US
Mailing Address - Phone:817-304-3261
Mailing Address - Fax:
Practice Address - Street 1:8100 HERNDON DR
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76116-8539
Practice Address - Country:US
Practice Address - Phone:817-304-3261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17980101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1620460Medicaid