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General NPI Number Information
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NPI Number | 1548823826
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Entity Type | Individual
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Provider Name | CHANELLA LATRE CLARK LPCC
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Gender | Female
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Dates
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Enumeration Date | 04/22/2019
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Last Update Date | 10/24/2022
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Provider Practice Location Address
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Address Line | 210 25TH AVE N STE 601
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City | NASHVILLE
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State | TN
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Zip | 37203-1631
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Country | US
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Telephone | 615-337-8709
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Fax |
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Provider Business Mailing Address
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Address Line | 1515 5TH AVE N APT 204
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City | NASHVILLE
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State | TN
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Zip | 37208-2798
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Country | US
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Telephone | 615-337-8709
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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 | 281173
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License Number State | KY
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