Basic Information
| Provider Information | |||||||||
| NPI: | 1235313388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | JEREMIAH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 E FIRST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524422084 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E FIRST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524423084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16872LICSW | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | HP84895 | 01 | MN | HEALTH PARTNERS | OTHER |