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General NPI Number Information
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NPI Number | 1245665363
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Entity Type | Individual
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Provider Name | RANDOLPH LAIRD CLARK MSW, LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 554 PIT RD
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City | BROWNSBURG
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State | IN
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Zip | 46112-9555
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Country | US
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Telephone | 317-742-9400
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Fax | 317-742-9414
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Provider Business Mailing Address
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Address Line | 554 PIT RD
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City | BROWNSBURG
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State | IN
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Zip | 46112-9555
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Country | US
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Telephone | 317-742-9400
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Fax | 317-742-9414
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34007681A
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License Number State | IN
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