MEDICARE: MS. SHANA ELAINE CLARK M.A., 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	09983	TX

General Provider Information

NPI Number	:	1942365622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANA ELAINE CLARK M.A., LPC

Provider Business Mailing Address
First Line	:	4219 RICHMOND AVE
Second Line	:	STE. 219
City	:	HOUSTON
State	:	TX
Zip	:	77027-6893
Country	:	US
Telephone Number	:	713-627-7070
Fax Number	:	713-627-9997

Provider Business Practice Location Address
First Line	:	4219 RICHMOND AVE
Second Line	:	STE. 219
City	:	HOUSTON
State	:	TX
Zip	:	77027-6893
Country	:	US
Telephone Number	:	713-627-7070
Fax Number	:	713-627-9997

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

Provider Enumeration Date	:	12/24/2006
Last Update Date	:	07/08/2007

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