MEDICARE: TAYLOR CLARK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	83790	TX

General Provider Information

NPI Number	:	1104546753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR CLARK LPC

Provider Business Mailing Address
First Line	:	7711 CALLAGHAN RD APT 501
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-2331
Country	:	US
Telephone Number	:	903-952-1201
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 GARDENDALE ST STE 104A
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3143
Country	:	US
Telephone Number	:	903-952-1201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2022
Last Update Date	:	09/01/2022

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Directions to “ TAYLOR CLARK LPC” Practice Location

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