Healthcare Provider Details

I. General information

NPI: 1497266555
Provider Name (Legal Business Name): LAKLISHA CLARK COUNSELOR AAS, MHFAB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 LANDERBROOK DR STE 301
MAYFIELD HEIGHTS OH
44124-4020
US

IV. Provider business mailing address

5900 LANDERBROOK DR STE 301
MAYFIELD HEIGHTS OH
44124-4020
US

V. Phone/Fax

Practice location:
  • Phone: 216-417-8813
  • Fax:
Mailing address:
  • Phone: 216-417-8813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16333
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: