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NPI Code Detail

MEDICARE: MR. CORY J CLARK LPC, LCDC, LMFTA

MEDICARE: MR. CORY J CLARK LPC, LCDC, LMFTA
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
1101YA0400XAddiction (Substance Use Disorder) Counselor11614TX
2101YP2500XProfessional Counselor67615TX

General Provider Information

NPI Number : 1780003574
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CORY J CLARK LPC, LCDC, LMFTA
Provider Business Mailing Address
First Line : 1430 COLLIER ST
Second Line :
City : AUSTIN
State : TX
Zip : 78704-2911
Country : US
Telephone Number : 512-472-4357
Fax Number : 512-703-1394
Provider Business Practice Location Address
First Line : 403 E 15TH ST
Second Line :
City : AUSTIN
State : TX
Zip : 78701-1437
Country : US
Telephone Number : 512-480-0920
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2014
Last Update Date : 04/09/2014

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