Provider Demographics
NPI:1992894992
Name:CLARK, FRED R (LSW)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SUMMERBROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:1020 GROSSCUP AVE
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-3128
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP009410761041C0700X
WV1704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVAP00941076OtherLSW
WV1704OtherLPC