=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396280970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERRY ANN M. CLARKE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2017
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1623 KINGS HWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-273-7601
-----------------------------------------------------
Fax | 718-307-6871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1545 ATLANTIC AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11213-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-613-7259
-----------------------------------------------------
Fax | 718-613-4381
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 094025-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------