Provider Demographics
NPI:1902488398
Name:CLARK, STEPHANIE (LMHC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 WATER OAKS LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-8633
Mailing Address - Country:US
Mailing Address - Phone:813-373-6565
Mailing Address - Fax:813-492-7214
Practice Address - Street 1:4215 WATER OAKS LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-8633
Practice Address - Country:US
Practice Address - Phone:813-373-6565
Practice Address - Fax:813-492-7214
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health