Basic Information
| Provider Information | |||||||||
| NPI: | 1962834515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CARA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TYNES | ||||||||
| OtherFirstName: | CARA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4615 GOVERNMENT ST | ||||||||
| Address2: | BUILDING 2 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708065922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259220445 | ||||||||
| FaxNumber: | 2259222658 | ||||||||
| Practice Location | |||||||||
| Address1: | 29437 HWY 63 | ||||||||
| Address2: | STE. 14 | ||||||||
| City: | LIVINGSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252831356 | ||||||||
| FaxNumber: | 2252831705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2013 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | 12345 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.