Healthcare Provider Details

I. General information

NPI: 1659186138
Provider Name (Legal Business Name): CATHERINE ANNE CLARK LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

692 ELM ST
DERBY LINE VT
05830-8730
US

IV. Provider business mailing address

692 ELM ST
DERBY LINE VT
05830-8730
US

V. Phone/Fax

Practice location:
  • Phone: 802-673-8430
  • Fax:
Mailing address:
  • Phone: 802-673-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0136420
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: