Basic Information
| Provider Information | |||||||||
| NPI: | 1174606776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2185 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165054747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148783433 | ||||||||
| FaxNumber: | 8148783488 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165081832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144545686 | ||||||||
| FaxNumber: | 8144548946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW017348 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.