Healthcare Provider Details

I. General information

NPI: 1760495329
Provider Name (Legal Business Name): ALICE M CLARK MA, LPC, CACIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5377 MANHATTAN CIR SUITE 200
BOULDER CO
80303-4333
US

IV. Provider business mailing address

1786 YAUPON AVE
BOULDER CO
80304-4364
US

V. Phone/Fax

Practice location:
  • Phone: 303-263-7855
  • Fax:
Mailing address:
  • Phone: 303-263-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5499
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1687
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: