Provider Demographics
NPI:1699276287
Name:CLARK, ADAM (LCSW)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1699
Mailing Address - Country:US
Mailing Address - Phone:541-396-3101
Mailing Address - Fax:
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1755
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099249081041C0700X
ORL81221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical