Provider Demographics
NPI:1306806955
Name:CLARK, BECKY SUE (LCSW)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:SUE
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 1:1635 POND VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6719
Mailing Address - Country:US
Mailing Address - Phone:207-590-8477
Mailing Address - Fax:
Practice Address - Street 1:1635 POND VIEW CT
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6719
Practice Address - Country:US
Practice Address - Phone:207-590-8477
Practice Address - Fax:207-518-9589
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-9921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical