Healthcare Provider Details

I. General information

NPI: 1629432182
Provider Name (Legal Business Name): CLARK COMMUNITY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N CENTRAL AVE
MONETT MO
65708
US

IV. Provider business mailing address

PO BOX 100
PIERCE CITY MO
65723-2100
US

V. Phone/Fax

Practice location:
  • Phone: 417-235-6610
  • Fax: 417-476-1082
Mailing address:
  • Phone: 417-476-1000
  • Fax: 417-476-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: ANGELA SUPPLEE
Title or Position: PAYER ENROLLMENT MANAGER
Credential:
Phone: 417-476-1013