Provider Demographics
NPI:1215670369
Name:CLARK, ANDREA MAE (MSW, LSW)
Entity type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:MAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:MS
Other - First Name:ANDI
Other - Middle Name:MAE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:309-779-2031
Mailing Address - Fax:
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5351
Practice Address - Country:US
Practice Address - Phone:309-779-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker