Healthcare Provider Details

I. General information

NPI: 1306785647
Provider Name (Legal Business Name): ETHAN ALEXANDER CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 DELANO AVE
CHILLICOTHEE OH
45601-2250
US

IV. Provider business mailing address

207 DELANO AVE
CHILLICOTHEE OH
45601-2250
US

V. Phone/Fax

Practice location:
  • Phone: 740-851-7962
  • Fax:
Mailing address:
  • Phone: 740-851-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: