Healthcare Provider Details

I. General information

NPI: 1689608952
Provider Name (Legal Business Name): GREGORY D CLARK MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 BROADWAY N STE 810
FARGO ND
58102-4949
US

IV. Provider business mailing address

118 BROADWAY N STE 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 NumberLICSW 2973
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier015066
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBCBS OF ND PIN
# 2
Identifier03Q32CL
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBCBS OF MN PIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: