Provider Demographics
NPI:1720837511
Name:CLARK, STACEY LYNNE (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13963 S PORTRUSH CT
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6793
Mailing Address - Country:US
Mailing Address - Phone:801-860-3552
Mailing Address - Fax:
Practice Address - Street 1:1062 E BAMBERGER DR
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-5504
Practice Address - Country:US
Practice Address - Phone:801-642-2193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5107906-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical