Provider Demographics
NPI:1750439998
Name:CLARK, KAFFIE RUTH (LMHC)
Entity type:Individual
Prefix:
First Name:KAFFIE
Middle Name:RUTH
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 DATE PALM DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-3227
Mailing Address - Country:US
Mailing Address - Phone:561-841-3990
Mailing Address - Fax:561-863-0087
Practice Address - Street 1:721 US HIGHWAY 1
Practice Address - Street 2:SUITE 108
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-4512
Practice Address - Country:US
Practice Address - Phone:561-841-3990
Practice Address - Fax:561-863-0087
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7312101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health