Provider Demographics
NPI:1144003328
Name:CLARK, ALYCIA M (LMSW)
Entity type:Individual
Prefix:
First Name:ALYCIA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:ALYCIA
Other - Middle Name:M
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1835 ESCONDIDO TER
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5202
Mailing Address - Country:US
Mailing Address - Phone:775-982-1000
Mailing Address - Fax:
Practice Address - Street 1:85 KIRMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1340
Practice Address - Country:US
Practice Address - Phone:775-982-5318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
NV10950-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst