Healthcare Provider Details

I. General information

NPI: 1144600800
Provider Name (Legal Business Name): GREGORY D. CLARK, MSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BROADWAY N SUITE 810
FARGO ND
58102-4949
US

IV. Provider business mailing address

118 BROADWAY N SUITE 810
FARGO ND
58102-4949
US

V. Phone/Fax

Practice location:
  • Phone: 701-799-8785
  • Fax: 701-205-4930
Mailing address:
  • Phone: 701-799-8785
  • Fax: 701-205-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2973
License Number StateND

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. GREGORY DARWIN CLARK
Title or Position: CLINICAL SOCIAL WORKER
Credential: MSW
Phone: 701-799-8785