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General NPI Number Information
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NPI Number | 1992322564
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Entity Type | Individual
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Provider Name | MARTHA ELIZABETH CLARK MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/30/2020
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Last Update Date | 04/25/2025
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Provider Practice Location Address
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Address Line | 6763 PAGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63133-1635
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Country | US
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Telephone | 314-379-8217
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Fax |
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Provider Business Mailing Address
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Address Line | 3309 S KINGSHIGHWAY BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63139-1101
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Country | US
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Telephone | 314-206-3700
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 2022045982
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License Number State | MO
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