Provider Demographics
NPI:1730605320
Name:CLARK, KAYLA (LPC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:CLARK
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 1:406 LEAFMORE RD SW APT B
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-3856
Mailing Address - Country:US
Mailing Address - Phone:404-736-5112
Mailing Address - Fax:
Practice Address - Street 1:106 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3128
Practice Address - Country:US
Practice Address - Phone:706-509-0130
Practice Address - Fax:706-237-6503
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007128101Y00000X
GALPC012786101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC012786OtherLICENSURE