MEDICARE: MRS. LESLIE SUSAN CLARK MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW 7521	FL

General Provider Information

NPI Number	:	1457489866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLIE SUSAN CLARK MSW, LCSW

Provider Business Mailing Address
First Line	:	2888 MAHAN DR STE 4
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5465
Country	:	US
Telephone Number	:	850-385-9046
Fax Number	:	850-385-9401

Provider Business Practice Location Address
First Line	:	2888 MAHAN DR STE 4
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5465
Country	:	US
Telephone Number	:	850-385-9046
Fax Number	:	850-385-9401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/09/2007

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