Healthcare Provider Details

I. General information

NPI: 1851118376
Provider Name (Legal Business Name): ALEXANDRIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 COLLINS BLVD STE 2
ASHTABULA OH
44004-6954
US

IV. Provider business mailing address

811 COLUMBUS AVE
ASHTABULA OH
44004-3547
US

V. Phone/Fax

Practice location:
  • Phone: 866-534-2639
  • Fax:
Mailing address:
  • Phone: 440-813-9670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2614492
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: