Provider Demographics
NPI:1992341283
Name:CLARK, NATASHA LEA (LPC)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:LEA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-1178
Mailing Address - Country:US
Mailing Address - Phone:660-359-4487
Mailing Address - Fax:
Practice Address - Street 1:6750 ANTIOCH RD STE 210
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-1260
Practice Address - Country:US
Practice Address - Phone:888-631-3938
Practice Address - Fax:913-608-5659
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2940101YM0800X
MO2015026281101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1376097246Medicaid