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General NPI Number Information
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NPI Number | 1497092704
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Entity Type | Individual
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Provider Name | LESLIE A. CLARK LPC, CSAC, CIR, ICS-
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Gender | Female
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Dates
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Enumeration Date | 01/07/2013
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 7071 S. 13TH STREET SUITE 100
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City | OAK CREEK
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State | WI
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Zip | 53154
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Country | US
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Telephone | 414-367-6698
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Fax |
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Provider Business Mailing Address
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Address Line | 11011 W. NORTH AVE. APT.309
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City | WAUWATOSA
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State | WI
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Zip | 53226
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Country | US
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Telephone | 414-367-6698
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 16215-132
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 1180-226
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 5204-125
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License Number State | WI
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