Basic Information
| Provider Information | |||||||||
| NPI: | 1831112671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JAND | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPCC, CRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CALLE DEL PINON | ||||||||
| Address2: | |||||||||
| City: | SANDIA PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870479691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | 5052562819 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO SE (116) | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE, | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | 5052562819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0077551 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.