Healthcare Provider Details

I. General information

NPI: 1255820569
Provider Name (Legal Business Name): BRENDA CLARK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 08/23/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 CLOCK POINTE TRL STE 105
STOW OH
44224-2989
US

IV. Provider business mailing address

3918 CLOCK POINTE TRL STE 105
STOW OH
44224-2989
US

V. Phone/Fax

Practice location:
  • Phone: 760-593-8011
  • Fax:
Mailing address:
  • Phone: 760-593-8011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.2305077-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: