MEDICARE: MR. CLARK DAVID AUSLOOS MA, LPC, LPSC, NCC

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	101YP2500X	Professional Counselor	C.1700624	OH

General Provider Information

NPI Number	:	1689188914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARK DAVID AUSLOOS MA, LPC, LPSC, NCC

Provider Business Mailing Address
First Line	:	26863 CARRONADE DR APT 7201
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-6432
Country	:	US
Telephone Number	:	920-948-2467
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 W SOUTH BOUNDARY ST STE A
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5238
Country	:	US
Telephone Number	:	419-931-3020
Fax Number	:

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

Provider Enumeration Date	:	11/22/2017
Last Update Date	:	11/22/2017

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