MEDICARE: CLARISSA CLARKSON 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	34006656A	IN

General Provider Information

NPI Number	:	1255672630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA CLARKSON MSW, LCSW

Provider Business Mailing Address
First Line	:	2821 SUNNYFIELD CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46228-3100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2821 SUNNYFIELD CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46228-3100
Country	:	US
Telephone Number	:	317-500-2201
Fax Number	:

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

Provider Enumeration Date	:	03/08/2013
Last Update Date	:	03/08/2013

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