Provider Demographics
NPI:1609694058
Name:CLARK, ABIGAIL CLAIRE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:CLAIRE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 BANKSTON DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-8491
Mailing Address - Country:US
Mailing Address - Phone:336-830-3391
Mailing Address - Fax:
Practice Address - Street 1:5601 DEMOCRACY DR STE 255
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3699
Practice Address - Country:US
Practice Address - Phone:940-765-9029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93935101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional