Provider Demographics
NPI:1730713587
Name:MAHONEY-CLARK, PEGGY B (LMSW)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:B
Last Name:MAHONEY-CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4301
Mailing Address - Country:US
Mailing Address - Phone:318-779-0434
Mailing Address - Fax:318-210-0000
Practice Address - Street 1:2219 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4301
Practice Address - Country:US
Practice Address - Phone:318-779-0434
Practice Address - Fax:318-210-0000
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-01
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10023171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty