Healthcare Provider Details

I. General information

NPI: 1487280707
Provider Name (Legal Business Name): SABRINA CLARK PSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

IV. Provider business mailing address

2313 14TH ST
LAKE CHARLES LA
70601-7923
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-0324
  • Fax: 337-475-8917
Mailing address:
  • Phone: 713-689-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: