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General NPI Number Information
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NPI Number | 1518205087
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Entity Type | Individual
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Provider Name | CRISTAL R CLARK LPC
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Gender | Female
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Dates
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Enumeration Date | 01/17/2013
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Last Update Date | 03/01/2014
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Provider Practice Location Address
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Address Line | 3327 WINTHROP AVE SUITE 205
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City | FORT WORTH
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State | TX
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Zip | 76116-5613
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Country | US
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Telephone | 817-994-6962
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Fax | 817-984-1102
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Provider Business Mailing Address
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Address Line | 3327 WINTHROP AVE SUITE 205
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City | FORT WORTH
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State | TX
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Zip | 76116-5613
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Country | US
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Telephone | 817-994-6962
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Fax | 817-984-1102
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 68323
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License Number State | TX
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