Healthcare Provider Details

I. General information

NPI: 1508231085
Provider Name (Legal Business Name): DERWIN CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RIDGWAY RD STE 1C
PINE BLUFF AR
71603-7610
US

IV. Provider business mailing address

1301 RIDGWAY RD STE 1C
PINE BLUFF AR
71603-7610
US

V. Phone/Fax

Practice location:
  • Phone: 870-395-7341
  • Fax: 870-395-7377
Mailing address:
  • Phone: 870-395-7341
  • Fax: 870-395-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1354
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: