Healthcare Provider Details

I. General information

NPI: 1679539076
Provider Name (Legal Business Name): PHYLLIS SUSAN CLARK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN CLARK MSW

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S LINCOLN AVE
STEAMBOAT SPRINGS CO
80487-8907
US

IV. Provider business mailing address

715 HORIZON DR STE 225
GRAND JUNCTION CO
81506-8743
US

V. Phone/Fax

Practice location:
  • Phone: 970-879-2141
  • Fax: 970-879-7912
Mailing address:
  • Phone: 970-683-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.00000022
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: