Healthcare Provider Details

I. General information

NPI: 1992894992
Provider Name (Legal Business Name): FRED R CLARK LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 GROSSCUP AVE
DUNBAR WV
25064-3128
US

IV. Provider business mailing address

107 SUMMERBROOK LANE
HURRICANE WV
25526
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7851
  • Fax: 304-525-1073
Mailing address:
  • Phone: 304-525-7851
  • Fax: 304-525-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1704
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAP00941076
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: