Basic Information
| Provider Information | |||||||||
| NPI: | 1003149808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DARCIE | ||||||||
| MiddleName: | RUPERT | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPCC, LCDCIII | ||||||||
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| 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: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 991819 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | E08331-5 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | EO8331 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | EO8331 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0184758 | 05 | OH | MEDICAID |