MEDICARE: MAURA TUKEY CLARK MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC11088	ME
2	101YM0800X	Mental Health Counselor	LC11088	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31686	OTHER	MA	HEALTH NEW ENGLAND

General Provider Information

NPI Number	:	1083632491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAURA TUKEY CLARK MSW, LCSW

Provider Business Mailing Address
First Line	:	180 HATCH RD
Second Line	:
City	:	NEW GLOUCESTER
State	:	ME
Zip	:	04260-3663
Country	:	US
Telephone Number	:	207-926-5021
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 HATCH RD
Second Line	:
City	:	NEW GLOUCESTER
State	:	ME
Zip	:	04260-3663
Country	:	US
Telephone Number	:	207-926-5021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	11/04/2010

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