Provider Demographics
NPI:1972613255
Name:CLARK, RONALD LEE (MSW LCSWR)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 EAST EIGHT ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3330
Mailing Address - Country:US
Mailing Address - Phone:315-343-5081
Mailing Address - Fax:315-342-1133
Practice Address - Street 1:106 W UTICA ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3330
Practice Address - Country:US
Practice Address - Phone:315-326-0155
Practice Address - Fax:315-342-1133
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0538491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical