=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386779759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERARD CLARK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 S 69TH ST
-----------------------------------------------------
City | UPPER DARBY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19082-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-352-8943
-----------------------------------------------------
Fax | 610-352-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 569 PARKER AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-509-6634
-----------------------------------------------------
Fax | 610-352-8880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW-002765-E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------