Provider Demographics
NPI:1902130206
Name:CLARK, HEATHER ANN (MS CPRP LPCC)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CPRP LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 BRITT ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4983
Mailing Address - Country:US
Mailing Address - Phone:505-298-0780
Mailing Address - Fax:
Practice Address - Street 1:3608 BRITT ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-4983
Practice Address - Country:US
Practice Address - Phone:505-934-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0096921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional