Healthcare Provider Details

I. General information

NPI: 1851834733
Provider Name (Legal Business Name): SHEMIKA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 CENTRAL AVE
MONROE LA
71203
US

IV. Provider business mailing address

850 KALISTE SALOOM RD
LAFAYETTE LA
70508-4230
US

V. Phone/Fax

Practice location:
  • Phone: 318-340-1535
  • Fax:
Mailing address:
  • Phone: 337-234-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: