Healthcare Provider Details

I. General information

NPI: 1528905015
Provider Name (Legal Business Name): EMILY CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14337 N GRAY RD
CARMEL IN
46033-9630
US

IV. Provider business mailing address

14337 N GRAY RD
CARMEL IN
46033-9630
US

V. Phone/Fax

Practice location:
  • Phone: 219-851-3473
  • Fax:
Mailing address:
  • Phone: 219-851-3473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005999A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: