Provider Demographics
NPI:1992070437
Name:CLARK-FOSTER, MYRA DAWN (LPCC-S)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:DAWN
Last Name:CLARK-FOSTER
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8021 RAVINE RUN LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-6457
Mailing Address - Country:US
Mailing Address - Phone:614-361-1255
Mailing Address - Fax:
Practice Address - Street 1:3 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081
Practice Address - Country:US
Practice Address - Phone:614-946-0639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0004034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional