MEDICARE: MR. ROBERT LUCIEN CLARK L.P.C., N.C.C.

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	2168	GA

General Provider Information

NPI Number	:	1932282704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT LUCIEN CLARK L.P.C., N.C.C.

Provider Business Mailing Address
First Line	:	19 LAKE PT
Second Line	:
City	:	SAUTEE NACOOCHEE
State	:	GA
Zip	:	30571-5180
Country	:	US
Telephone Number	:	706-878-1485
Fax Number	:

Provider Business Practice Location Address
First Line	:	42 NORTH AVENUE
Second Line	:
City	:	CLEVELAND
State	:	GA
Zip	:	30528-1398
Country	:	US
Telephone Number	:	706-348-8674
Fax Number	:	706-348-8676

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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