Healthcare Provider Details

I. General information

NPI: 1801452040
Provider Name (Legal Business Name): GEORGE CLARK LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MERRICK ST
WORCESTER MA
01609-1937
US

IV. Provider business mailing address

10 MECHANIC ST STE 302
WORCESTER MA
01608-2419
US

V. Phone/Fax

Practice location:
  • Phone: 508-797-6100
  • Fax: 508-797-0693
Mailing address:
  • Phone: 508-792-5400
  • Fax: 508-831-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number112041
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: