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NPI Code Detail

MEDICARE: RYAN CLARK LCSW, LCADC

MEDICARE: RYAN CLARK LCSW, LCADC
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
11041C0700XClinical Social WorkerLCSW00001327KY

General Provider Information

NPI Number : 1730931197
Entity Type Code : Individual
Provider Name (Legal Business Name) : RYAN CLARK LCSW, LCADC
Provider Business Mailing Address
First Line : 3022 PETTY JAY RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40220-2828
Country : US
Telephone Number : 404-395-2355
Fax Number :
Provider Business Practice Location Address
First Line : 1028 BARRET AVE
Second Line :
City : LOUISVILLE
State : KY
Zip : 40204-1667
Country : US
Telephone Number : 404-395-2355
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/01/2024
Last Update Date : 01/28/2026

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