Provider Demographics
NPI:1053421453
Name:CLARK, DEBORAH A (LPC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 WASHINGTON AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4327
Mailing Address - Country:US
Mailing Address - Phone:757-245-0217
Mailing Address - Fax:757-245-4918
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1769
Practice Address - Country:US
Practice Address - Phone:757-788-0600
Practice Address - Fax:757-788-0932
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-45573Medicaid
VA49-45573Medicaid