Healthcare Provider Details

I. General information

NPI: 1295285500
Provider Name (Legal Business Name): KAYLA CLARK LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 SEARCY WAY
BOWLING GREEN KY
42103-7168
US

IV. Provider business mailing address

942 SEARCY WAY
BOWLING GREEN KY
42103-7168
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-8112
  • Fax: 270-781-8114
Mailing address:
  • Phone: 270-781-8112
  • Fax: 270-781-8114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number166091
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: