Provider Demographics
NPI:1528730652
Name:CLARK, DAWN
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
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 1:902 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 16TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7973
Practice Address - Country:US
Practice Address - Phone:507-516-0030
Practice Address - Fax:507-516-0031
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304749101YA0400X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)