Provider Demographics
NPI:1144212374
Name:CLARK, GLENDA S (LCSW)
Entity type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BUGLE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-6609
Mailing Address - Country:US
Mailing Address - Phone:863-853-2213
Mailing Address - Fax:813-354-9436
Practice Address - Street 1:3333 W KENNEDY BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2976
Practice Address - Country:US
Practice Address - Phone:813-354-9444
Practice Address - Fax:813-354-9436
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00036721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical