Healthcare Provider Details

I. General information

NPI: 1487913232
Provider Name (Legal Business Name): KEVIN CLARK LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 10/13/2026
Certification Date: 10/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 BROADWAY
RAYNHAM MA
02767-1973
US

IV. Provider business mailing address

269 GREENVILLE AVE STE E
JOHNSTON RI
02919-2656
US

V. Phone/Fax

Practice location:
  • Phone: 508-202-1811
  • Fax:
Mailing address:
  • Phone: 401-251-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: