=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285123711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD L CLARK, MSW, CSW, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2018
-----------------------------------------------------
Last Update Date | 05/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 W UTICA ST STE G
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-3059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-326-0155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 E 8TH ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MR. RONALD L CLARK
-----------------------------------------------------
Credential | LCSW-R
-----------------------------------------------------
Telephone | 315-326-0155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R053849
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------