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General NPI Number Information
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NPI Number | 1780003574
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Entity Type | Individual
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Provider Name | CORY J CLARK LPC, LCDC, LMFTA
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Gender | Male
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Dates
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Enumeration Date | 04/09/2014
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Last Update Date | 04/09/2014
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Provider Practice Location Address
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Address Line | 403 E 15TH ST
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City | AUSTIN
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State | TX
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Zip | 78701-1437
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Country | US
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Telephone | 512-480-0920
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Fax |
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Provider Business Mailing Address
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Address Line | 1430 COLLIER ST
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City | AUSTIN
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State | TX
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Zip | 78704-2911
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Country | US
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Telephone | 512-472-4357
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Fax | 512-703-1394
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 11614
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 67615
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License Number State | TX
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