MEDICARE: ETHAN 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1821929324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN CLARK

Provider Business Mailing Address
First Line	:	1052 WATT ST APT C
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89509-2869
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3724 LAKESIDE DR STE 200
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89509-5293
Country	:	US
Telephone Number	:	775-895-0712
Fax Number	:

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

Provider Enumeration Date	:	05/26/2026
Last Update Date	:	05/26/2026

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Directions to “ ETHAN CLARK ” Practice Location

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