Provider Demographics
NPI:1861717597
Name:CLARK, JUDITH ANN (MPS, EDS)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPS, EDS
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:CLARK BROOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPS, EDS
Mailing Address - Street 1:244 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1217
Mailing Address - Country:US
Mailing Address - Phone:859-233-2225
Mailing Address - Fax:859-233-9498
Practice Address - Street 1:244 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1217
Practice Address - Country:US
Practice Address - Phone:859-233-2225
Practice Address - Fax:859-233-9498
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF854398101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)