Healthcare Provider Details

I. General information

NPI: 1316545486
Provider Name (Legal Business Name): KAISA CLARK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 HALL DR
AMHERST MA
01002-2751
US

IV. Provider business mailing address

31 HALL DR
AMHERST MA
01002-2751
US

V. Phone/Fax

Practice location:
  • Phone: 413-256-8561
  • Fax: 866-644-0869
Mailing address:
  • Phone: 413-256-8561
  • Fax: 866-644-0869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119672
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierNONE
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: