Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | 000189998 | TN |
N | 101YM0800X | Mental Health Counselor | 000189998 | TN |
Y | 101YS0200X | School Counselor | 000189998 | TN |
N | 104100000X | Social Worker | 000189998 | TN |
N | 1041C0700X | Clinical Social Worker | 000189998 | TN |
N | 1041S0200X | School Social Worker | 000189998 | TN |
NPI | 1124598511 |
---|---|
Provider Name | Mr. Todd Anthony Lark, Sr. SR. |
First Address | Murfreesboro, TN 37128-4276 |
Second Address | Murfreesboro, TN 37128-4276 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2018 |
Last Update Date | 28/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1503964 | (05) | TN |