Basic Information
Provider Information
NPI: 1003149808
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARK
FirstName: DARCIE
MiddleName: RUPERT
NamePrefix: MRS.
NameSuffix:  
Credential: MS, LPCC, LCDCIII
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11 W MONUMENT AVE STE 100
Address2:  
City: DAYTON
State: OH
PostalCode: 454021293
CountryCode: US
TelephoneNumber: 9376711589
FaxNumber: 9374355865
Practice Location
Address1: 11 W MONUMENT AVE STE 100
Address2:  
City: DAYTON
State: OH
PostalCode: 454021293
CountryCode: US
TelephoneNumber: 9376796301
FaxNumber: 9376304391
Other Information
ProviderEnumerationDate: 09/10/2009
LastUpdateDate: 11/01/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400XE08331-5OHN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YA0400X991819OHN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800XEO8331OHY Behavioral Health & Social Service ProvidersCounselorMental Health
101YP2500XEO8331OHN Behavioral Health & Social Service ProvidersCounselorProfessional

ID Information
IDTypeStateIssuerDescription
018475805OH MEDICAID


Home