Provider Demographics
NPI:1962786160
Name:CLARK, STEVEN W (CAMF, COAMF, CDVF)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:CAMF, COAMF, CDVF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8812 YATES TERRACE NORTH
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443
Mailing Address - Country:US
Mailing Address - Phone:763-913-0130
Mailing Address - Fax:
Practice Address - Street 1:3300 BASS LAKE ROAD
Practice Address - Street 2:SUITE 314
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-913-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor