Healthcare Provider Details

I. General information

NPI: 1962834515
Provider Name (Legal Business Name): CARA MARIE CLARK CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARA TYNES LCSW

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29437 HWY 63 STE. 14
LIVINGSTON LA
70754
US

IV. Provider business mailing address

4615 GOVERNMENT ST BUILDING 2
BATON ROUGE LA
70806-5922
US

V. Phone/Fax

Practice location:
  • Phone: 225-283-1356
  • Fax: 225-283-1705
Mailing address:
  • Phone: 225-922-0445
  • Fax: 225-922-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12345
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: