MEDICARE: TONJA CHARLOTTE CLARK

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	101Y00000X	Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1255799797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONJA CHARLOTTE CLARK

Provider Business Mailing Address
First Line	:	2525 YOUREE DR STE 110
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71104-3600
Country	:	US
Telephone Number	:	318-425-9030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 YOUREE DR STE 110
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71104
Country	:	US
Telephone Number	:	318-425-9030
Fax Number	:

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

Provider Enumeration Date	:	01/28/2016
Last Update Date	:	05/31/2026

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Directions to “ TONJA CHARLOTTE CLARK ” Practice Location

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