Provider Demographics
NPI:1285795997
Name:CLARK, MADELON RUDMAN (LISW MSW)
Entity type:Individual
Prefix:
First Name:MADELON
Middle Name:RUDMAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LISW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WILMUTH AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:OH
Mailing Address - Zip Code:45215
Mailing Address - Country:US
Mailing Address - Phone:513-948-8731
Mailing Address - Fax:
Practice Address - Street 1:10915 READING RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241
Practice Address - Country:US
Practice Address - Phone:513-891-7171
Practice Address - Fax:513-554-0200
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI37781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCLSW01112Medicare ID - Type Unspecified