MEDICARE: MRS. KIMBERLY ANN CLARK MHR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		OK

General Provider Information

NPI Number	:	1053591875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY ANN CLARK MHR

Provider Business Mailing Address
First Line	:	1516 S BOSTON AVE
Second Line	:	SUITE 100
City	:	TULSA
State	:	OK
Zip	:	74119-4003
Country	:	US
Telephone Number	:	918-561-6000
Fax Number	:	918-561-6001

Provider Business Practice Location Address
First Line	:	1516 S BOSTON AVE
Second Line	:	SUITE 100
City	:	TULSA
State	:	OK
Zip	:	74119-4003
Country	:	US
Telephone Number	:	918-561-6000
Fax Number	:	918-561-6001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2007
Last Update Date	:	01/22/2010

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