Healthcare Provider Details

I. General information

NPI: 1538373337
Provider Name (Legal Business Name): TERESA CLARK LCSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 BATH RD
WISCASSET ME
04578-4830
US

IV. Provider business mailing address

721 BATH RD
WISCASSET ME
04578-4830
US

V. Phone/Fax

Practice location:
  • Phone: 207-882-5300
  • Fax:
Mailing address:
  • Phone: 207-882-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC3953
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10536
License Number StateME

VII. Legacy identifiers

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

# 1
Identifier82-2931653
Identifier TypeOTHER
Identifier StateME
Identifier IssuerTAX ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: