Provider Demographics
NPI:1194235382
Name:CLARK, BROOKE AINYA (LCSWA, LISW-CP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:AINYA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSWA, LISW-CP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:AINYA
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWA, LISW-CP
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:4925 LACROSS RD STE 111
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6512
Practice Address - Country:US
Practice Address - Phone:843-552-1220
Practice Address - Fax:843-552-0502
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1041C0700X
SC133701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty