Provider Demographics
NPI:1538373337
Name:CLARK, TERESA (LCSW, LADC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 BATH RD
Mailing Address - Street 2:
Mailing Address - City:WISCASSET
Mailing Address - State:ME
Mailing Address - Zip Code:04578-4830
Mailing Address - Country:US
Mailing Address - Phone:207-882-5300
Mailing Address - Fax:
Practice Address - Street 1:721 BATH RD
Practice Address - Street 2:
Practice Address - City:WISCASSET
Practice Address - State:ME
Practice Address - Zip Code:04578-4830
Practice Address - Country:US
Practice Address - Phone:207-882-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3953101YA0400X
MELC105361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME82-2931653OtherTAX ID