=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972613255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD LEE CLARK MSW LCSWR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 W UTICA ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-326-0155
-----------------------------------------------------
Fax | 315-342-1133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 EAST EIGHT ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-343-5081
-----------------------------------------------------
Fax | 315-342-1133
-----------------------------------------------------
=====================================================
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 | R053849
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------