Provider Demographics
NPI:1194248187
Name:CLARK, LISA ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 WINDROW WAY
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-3679
Mailing Address - Country:US
Mailing Address - Phone:610-306-1190
Mailing Address - Fax:
Practice Address - Street 1:1114 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4401
Practice Address - Country:US
Practice Address - Phone:866-477-5345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00014621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical