1649650565 NPI number — CLARK GERALD PERKINS NCC, LPC

Table of content: CLARK GERALD PERKINS NCC, LPC (NPI 1649650565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649650565 NPI number — CLARK GERALD PERKINS NCC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERKINS
Provider First Name:
CLARK
Provider Middle Name:
GERALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NCC, LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649650565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1431 7TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57006-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-691-7630
Provider Business Mailing Address Fax Number:
605-692-4906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-691-7630
Provider Business Practice Location Address Fax Number:
605-692-4906
Provider Enumeration Date:
06/05/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LPC 595 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)