Healthcare Provider Details

I. General information

NPI: 1558760843
Provider Name (Legal Business Name): ALYSIA CLARKE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108-19 ROCKAWAY BLVD
OZONE PARK NY
11420
US

IV. Provider business mailing address

108-19 ROCKAWAY BLVD
OZONE PARK NY
11420
US

V. Phone/Fax

Practice location:
  • Phone: 718-327-7202
  • Fax: 718-327-7203
Mailing address:
  • Phone: 718-327-7202
  • Fax: 718-327-7203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number090985-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: