Healthcare Provider Details

I. General information

NPI: 1194400085
Provider Name (Legal Business Name): CALEB S CLARK LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 ASHWOOD DR
TIFFIN OH
44883-1908
US

IV. Provider business mailing address

1925 HAYES AVE
SANDUSKY OH
44870-4737
US

V. Phone/Fax

Practice location:
  • Phone: 419-448-9440
  • Fax:
Mailing address:
  • Phone: 419-557-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2406123
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE.2607304
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: