Healthcare Provider Details

I. General information

NPI: 1336656271
Provider Name (Legal Business Name): VANESSA CLARK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2018
Last Update Date: 01/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76605 GALLATIN RD
GALLATIN GATEWAY MT
59730-8711
US

IV. Provider business mailing address

PO BOX 102
GALLATIN GATEWAY MT
59730-0102
US

V. Phone/Fax

Practice location:
  • Phone: 406-498-3235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24163
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: