Provider Demographics
NPI:1154008407
Name:CLARK, CARSON (MSW)
Entity type:Individual
Prefix:MRS
First Name:CARSON
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 EAST 87TH ST
Mailing Address - Street 2:4TH FLOOR/P.O. BOX 656
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128
Mailing Address - Country:US
Mailing Address - Phone:212-876-7427
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L. LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120607104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker