Healthcare Provider Details

I. General information

NPI: 1922299122
Provider Name (Legal Business Name): ANNE CLARK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 N SHOOP AVE STE 1
WAUSEON OH
43567-1857
US

IV. Provider business mailing address

1115 N SHOOP AVE STE 1
WAUSEON OH
43567-1857
US

V. Phone/Fax

Practice location:
  • Phone: 419-335-6122
  • Fax: 419-318-4157
Mailing address:
  • Phone: 419-335-6122
  • Fax: 419-318-4157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number031136
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE4140
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: