Provider Demographics
NPI:1427135185
Name:CLARK, DOUGLAS JAMES (LICSW)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEETING HOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:EAST SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537-1513
Mailing Address - Country:US
Mailing Address - Phone:508-888-7369
Mailing Address - Fax:
Practice Address - Street 1:BROCKTON VA MEDICAL CENTER
Practice Address - Street 2:940 BELMONT ST.
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:774-826-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1066101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical