Healthcare Provider Details

I. General information

NPI: 1982176483
Provider Name (Legal Business Name): SAMANTHA D CLARK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 LAMONT ST
JOHNSON CITY TN
37604-5453
US

IV. Provider business mailing address

809 LAMONT ST
JOHNSON CITY TN
37604-5453
US

V. Phone/Fax

Practice location:
  • Phone: 423-335-0863
  • Fax:
Mailing address:
  • Phone: 423-926-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW0000010976
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: