Healthcare Provider Details

I. General information

NPI: 1639937089
Provider Name (Legal Business Name): CASSIDY ANN CLARK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SPRINGS RD
BEDFORD MA
01730-1114
US

IV. Provider business mailing address

35 WESTGATE RD APT 5
CHESTNUT HILL MA
02467-3409
US

V. Phone/Fax

Practice location:
  • Phone: 781-506-2366
  • Fax:
Mailing address:
  • Phone: 860-304-8194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1141497
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number229421
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: