Provider Demographics
NPI:1861138349
Name:CLARK, CAROL JEAN
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 DIEHL DR
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-7415
Mailing Address - Country:US
Mailing Address - Phone:412-952-4037
Mailing Address - Fax:
Practice Address - Street 1:402 DIEHL DR
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-7415
Practice Address - Country:US
Practice Address - Phone:412-952-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW136918104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker