MEDICARE: KATHERINE DIANE 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	1898	CO
2	163W00000X	Registered Nurse	91681	CO

General Provider Information

NPI Number	:	1275791949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE DIANE CLARK LPC

Provider Business Mailing Address
First Line	:	220 RUSKIN DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-2522
Country	:	US
Telephone Number	:	719-572-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 W MIDLAND AVE
Second Line	:	SUITE 202
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-3144
Country	:	US
Telephone Number	:	719-687-2880
Fax Number	:	719-686-0738

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

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	05/29/2008

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