Provider Demographics
NPI:1972700912
Name:CLARK, THERESA MARIE (LPC, RPT, NCC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC, RPT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1376
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-8376
Mailing Address - Country:US
Mailing Address - Phone:785-259-5576
Mailing Address - Fax:
Practice Address - Street 1:108 E 12TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-3668
Practice Address - Country:US
Practice Address - Phone:785-259-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLPC 916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional