MEDICARE: KAFFIE RUTH CLARK LMHC

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	101YM0800X	Mental Health Counselor	MH7312	FL

General Provider Information

NPI Number	:	1750439998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAFFIE RUTH CLARK LMHC

Provider Business Mailing Address
First Line	:	612 DATE PALM DR
Second Line	:
City	:	LAKE PARK
State	:	FL
Zip	:	33403-3227
Country	:	US
Telephone Number	:	561-841-3990
Fax Number	:	561-863-0087

Provider Business Practice Location Address
First Line	:	721 US HIGHWAY 1
Second Line	:	SUITE 108
City	:	NORTH PALM BEACH
State	:	FL
Zip	:	33408-4512
Country	:	US
Telephone Number	:	561-841-3990
Fax Number	:	561-863-0087

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

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	07/08/2007

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