Provider Demographics
NPI:1699026773
Name:CLARK, REBECCA ANN (PHD, LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:270-535-2545
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:270-535-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1151-3714C1041C0700X
GACSW0077351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1151-3714COtherALABAMA BOARD OF SOCIAL WORK-LCSW-PIP
AL1151-3714COtherALABAMA BOARD OF SOCIAL WORK-LCSW-PIP