Provider Demographics
NPI:1871071639
Name:CLARK, KESSALYN RAE (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:KESSALYN
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-6147
Mailing Address - Country:US
Mailing Address - Phone:406-475-4684
Mailing Address - Fax:
Practice Address - Street 1:501 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-2865
Practice Address - Country:US
Practice Address - Phone:406-442-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-31878101YA0400X
MTBBH-LCSW-LIC-55626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT92-2641389OtherIRS