MEDICARE: DR. SUSAN CLARK LCSW-S

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	50038	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881754109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN CLARK LCSW-S

Provider Business Mailing Address
First Line	:	3101 N BRITAIN RD
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-4559
Country	:	US
Telephone Number	:	214-395-7094
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 W MAGNOLIA AVE
Second Line	:	208
City	:	FT WORTH
State	:	TX
Zip	:	76104-4009
Country	:	US
Telephone Number	:	817-912-8006
Fax Number	:

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

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	12/16/2022

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