Provider Demographics
NPI:1538273826
Name:CLARK, CARLA GAFF (EDD, HSPP)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:GAFF
Last Name:CLARK
Suffix:
Gender:F
Credentials:EDD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4371
Mailing Address - Country:US
Mailing Address - Phone:765-284-0879
Mailing Address - Fax:765-284-1480
Practice Address - Street 1:3111 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4371
Practice Address - Country:US
Practice Address - Phone:765-284-0879
Practice Address - Fax:765-284-1480
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000210033OtherANTHEAM BCBS
INS29499Medicare UPIN
IN945500DMedicare ID - Type Unspecified