Provider Demographics
NPI:1447629738
Name:CLARK, TRACI B (LPC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LEIGH
Other - Last Name:BOYETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:110 LAKE POWELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-2107
Mailing Address - Country:US
Mailing Address - Phone:318-614-4796
Mailing Address - Fax:
Practice Address - Street 1:110 LAKE POWELL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-2107
Practice Address - Country:US
Practice Address - Phone:318-614-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4065101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor