MEDICARE: ANDREA CLARK

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

General Provider Information

NPI Number	:	1508649070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA CLARK

Provider Business Mailing Address
First Line	:	1530 VANCE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-2246
Country	:	US
Telephone Number	:	260-200-3988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 VANCE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-2246
Country	:	US
Telephone Number	:	260-200-3988
Fax Number	:

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

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	09/03/2025

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