Provider Demographics
NPI:1386779759
Name:CLARK, GERARD
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2423
Mailing Address - Country:US
Mailing Address - Phone:215-509-6634
Mailing Address - Fax:610-352-8880
Practice Address - Street 1:225 S 69TH ST
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-4212
Practice Address - Country:US
Practice Address - Phone:610-352-8943
Practice Address - Fax:610-352-8880
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW-002765-E104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker