MEDICARE: TAMI CLARK

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	104100000X	Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13815	OTHER	KS	BSRB

General Provider Information

NPI Number	:	1134957756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMI CLARK

Provider Business Mailing Address
First Line	:	4106 W 6TH ST STE D
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-4625
Country	:	US
Telephone Number	:	785-550-5380
Fax Number	:	785-550-5380

Provider Business Practice Location Address
First Line	:	4106 W 6TH ST STE D
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-4625
Country	:	US
Telephone Number	:	785-550-5380
Fax Number	:	785-550-5380

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

Provider Enumeration Date	:	07/24/2024
Last Update Date	:	03/09/2026

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Directions to “ TAMI CLARK ” Practice Location

Language	Start Address	Practice Location

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