MEDICARE: MS. KELLY CHRISTINA 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	77082	TX

General Provider Information

NPI Number	:	1659017200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY CHRISTINA CLARK LPC

Provider Business Mailing Address
First Line	:	3116 STONEHENGE LN
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-5214
Country	:	US
Telephone Number	:	214-412-7629
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S 14TH ST
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-3358
Country	:	US
Telephone Number	:	214-412-7629
Fax Number	:

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

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	05/06/2022

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