Provider Demographics
NPI:1992322564
Name:CLARK, MARTHA ELIZABETH (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1101
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:
Practice Address - Street 1:6763 PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1635
Practice Address - Country:US
Practice Address - Phone:314-379-8217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022045982104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker