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General NPI Number Information
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NPI Number | 1578985552
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Entity Type | Individual
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Provider Name | NIKOLE CLARK MS
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Gender | Female
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Dates
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Enumeration Date | 01/10/2014
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Last Update Date | 01/10/2014
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Provider Practice Location Address
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Address Line | 210 COURT ST STE 4
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City | WATERTOWN
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State | NY
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Zip | 13601-4546
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Country | US
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Telephone | 315-783-0193
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Fax |
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Provider Business Mailing Address
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Address Line | 325 N MICHIGAN AVE
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City | WATERTOWN
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State | NY
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Zip | 13601-2936
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Country | US
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Telephone |
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 001882-1
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License Number State | NY
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