Provider Demographics
NPI:1528287026
Name:CLARK, SUSAN MARIE (BA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:SKAARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:316 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5218
Mailing Address - Country:US
Mailing Address - Phone:701-774-4600
Mailing Address - Fax:
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5218
Practice Address - Country:US
Practice Address - Phone:701-774-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54516Medicaid