Provider Demographics
NPI:1861211369
Name:CLARK, STEVEN M
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:M
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 1:600 UNION BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2113
Mailing Address - Country:US
Mailing Address - Phone:937-998-8009
Mailing Address - Fax:937-998-8028
Practice Address - Street 1:600 UNION BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2113
Practice Address - Country:US
Practice Address - Phone:937-998-8009
Practice Address - Fax:937-998-8028
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator