Provider Demographics
NPI:1861093049
Name:CLARK, KATELYN E (LAC)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 W 14TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-4848
Mailing Address - Country:US
Mailing Address - Phone:720-943-7080
Mailing Address - Fax:720-316-7577
Practice Address - Street 1:8805 W 14TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4848
Practice Address - Country:US
Practice Address - Phone:720-943-7080
Practice Address - Fax:720-316-7577
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
COACD.0002029101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor