Healthcare Provider Details

I. General information

NPI: 1962231795
Provider Name (Legal Business Name): BENJAMIN ALEX CLARK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 N CENTRAL AVE
PHOENIX AZ
85012-1889
US

IV. Provider business mailing address

4637 N 9TH ST
PHOENIX AZ
85014-3813
US

V. Phone/Fax

Practice location:
  • Phone: 602-764-7818
  • Fax:
Mailing address:
  • Phone: 617-309-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-22348
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberLCSW-22348
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: