MEDICARE: SANDRA CLARK LPC ASSOCIATE

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	95242	TX

General Provider Information

NPI Number	:	1194541631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA CLARK LPC ASSOCIATE

Provider Business Mailing Address
First Line	:	2709 MAY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-3337
Country	:	US
Telephone Number	:	646-243-8263
Fax Number	:

Provider Business Practice Location Address
First Line	:	2709 MAY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-3337
Country	:	US
Telephone Number	:	646-243-8263
Fax Number	:

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

Provider Enumeration Date	:	12/02/2024
Last Update Date	:	12/02/2024

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