Healthcare Provider Details

I. General information

NPI: 1700700648
Provider Name (Legal Business Name): KAITLYN MARGARET CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S WALNUT AVE
AMES IA
50010-6974
US

IV. Provider business mailing address

223 S WALNUT AVE
AMES IA
50010-6974
US

V. Phone/Fax

Practice location:
  • Phone: 515-368-3491
  • Fax:
Mailing address:
  • Phone: 515-368-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number140468
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: