Provider Demographics
NPI:1104513506
Name:CLARK, PATRICK MICHAEL (LGSW)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:MICHAEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 SIOUX LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-5201
Mailing Address - Country:US
Mailing Address - Phone:630-930-7799
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 322
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5465
Practice Address - Country:US
Practice Address - Phone:507-702-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN298341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical