Basic Information
| Provider Information | |||||||||
| NPI: | 1184790859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | LYNE | ||||||||
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| Credential: | M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7068 CONSTANTINE CT | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440605124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409426135 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12557 RAVENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402853568 | ||||||||
| FaxNumber: | 4402854552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | E 0002811 | OH | X | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | E 0002811 | OH | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.