MEDICARE: REBECCA A 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	20216	TX

General Provider Information

NPI Number	:	1295021608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA A CLARK LPC

Provider Business Mailing Address
First Line	:	PO BOX 99213
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-0213
Country	:	US
Telephone Number	:	682-885-4871
Fax Number	:	682-885-3936

Provider Business Practice Location Address
First Line	:	1525 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-4105
Country	:	US
Telephone Number	:	817-804-1100
Fax Number	:	817-299-8790

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	04/12/2021

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