Provider Demographics
NPI:1386142750
Name:CLARK, CANDACE LAUREN
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LAUREN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6057 DANA RD SW
Mailing Address - Street 2:
Mailing Address - City:SHERRODSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44675-9778
Mailing Address - Country:US
Mailing Address - Phone:303-705-2072
Mailing Address - Fax:
Practice Address - Street 1:919 2ND ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-1132
Practice Address - Country:US
Practice Address - Phone:330-454-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker