Nicole Lane Clark, LCSW

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

91794 Issued in CA

Practice address

31292 Alpine Meadows Rd
Shingletown, CA 96088-9462

Phone

(530) 474-3390

Fax

(530) 474-1407

NPI assigned

Jul 11, 2013

Last updated

May 21, 2021By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2013

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Shingletown Medical CenterGroup PAC ID 5294720736, 13 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Shingletown Medical Center

  • Federally Qualified Health Center (FQHC)
  • Shingletown, CA
  • NPI 1750387072
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1373500800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1621555200000",
    "number": "1467893032",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1005 MAGNOLIA AVE",
            "city": "REDDING",
            "state": "CA",
            "postal_code": "960010314",
            "telephone_number": "530-209-5545"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "31292 ALPINE MEADOWS RD",
            "city": "SHINGLETOWN",
            "state": "CA",
            "postal_code": "960889462",
            "telephone_number": "530-474-3390",
            "fax_number": "530-474-1407"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "43423 Division St",
            "address_purpose": "LOCATION",
            "city": "Lancaster",
            "state": "CA",
            "postal_code": "935354639",
            "country_code": "US",
            "telephone_number": "661-266-4783",
            "fax_number": "661-266-1210",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CLARK",
        "first_name": "NICOLE",
        "middle_name": "LANE",
        "name_prefix": "Mrs.",
        "credential": "LCSW",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2013-07-11",
        "last_updated": "2021-05-21",
        "certification_date": "2021-05-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "91794",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDI-CAL",
            "identifier": "95-2633765",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in Shingletown, CA
• Providers in Shingletown, CA by specialty
• Mental Health Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.