Healthcare Provider Details

I. General information

NPI: 1154608503
Provider Name (Legal Business Name): CHRISTY LYNN CLARK M.A. LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3978 ARBOL CT
BOULDER CO
80301-1752
US

IV. Provider business mailing address

1530 LEE HILL RD #7
BOULDER CO
80304-0877
US

V. Phone/Fax

Practice location:
  • Phone: 303-578-8871
  • Fax:
Mailing address:
  • Phone: 303-578-8871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-5772
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: