=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043463201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEILA SUZANNE CLARK LMSW, LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2008
-----------------------------------------------------
Last Update Date | 01/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 HILL 99
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12498-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-594-7034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 HILL 99
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12498-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-594-7034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 258103-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 099205-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------