Provider Demographics
NPI:1407697717
Name:CLARK, NICOLE ELIZABETH (LMSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8416B SHALLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1328
Mailing Address - Country:US
Mailing Address - Phone:315-885-0959
Mailing Address - Fax:
Practice Address - Street 1:7266 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2649
Practice Address - Country:US
Practice Address - Phone:315-458-0919
Practice Address - Fax:315-458-0954
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY123078104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health