MEDICARE: L CLARK

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
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1235285495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	L CLARK

Provider Business Mailing Address
First Line	:	5101 OLD HIGHWAY 5 UNIT 503
Second Line	:
City	:	LEBANON
State	:	GA
Zip	:	30146-0817
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 CREEKSTONE RDG
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3746
Country	:	US
Telephone Number	:	770-233-7580
Fax Number	:

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

Provider Enumeration Date	:	01/28/2007
Last Update Date	:	03/17/2023

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Directions to “ L CLARK ” Practice Location

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