Healthcare Provider Details

I. General information

NPI: 1144292574
Provider Name (Legal Business Name): PATRICK J. CLARK MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6055 MEXICO RD
ST PETERS MO
63376-1632
US

IV. Provider business mailing address

9200 WATSON RD SUITE G101
SAINT LOUIS MO
63126-1528
US

V. Phone/Fax

Practice location:
  • Phone: 636-498-2273
  • Fax: 636-498-0390
Mailing address:
  • Phone: 314-367-5500
  • Fax: 314-843-9212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2003007957
License Number StateMO

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: