Provider Demographics
NPI:1730344987
Name:CLARK-DENT, TINA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:CLARK-DENT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19402 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4601
Mailing Address - Country:US
Mailing Address - Phone:602-689-2337
Mailing Address - Fax:623-322-8721
Practice Address - Street 1:2120 S MCCLINTOCK DR STE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-887-9701
Is Sole Proprietor?:No
Enumeration Date:2008-07-26
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12988101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health