Provider Demographics
NPI:1538990866
Name:CLARK, CORDELL L
Entity type:Individual
Prefix:
First Name:CORDELL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 DEBORAH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-4635
Mailing Address - Country:US
Mailing Address - Phone:317-503-5896
Mailing Address - Fax:
Practice Address - Street 1:4118 DEBORAH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-4635
Practice Address - Country:US
Practice Address - Phone:317-503-5896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker