Basic Information
Provider Information | |||||||||
NPI: | 1730637109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 N BEAVER ST | ||||||||
Address2: | PAYER CREDENTIALING | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860013118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282136235 | ||||||||
FaxNumber: | 9282136292 | ||||||||
Practice Location | |||||||||
Address1: | 294 W STATE ROUTE 89A | ||||||||
Address2: |   | ||||||||
City: | COTTONWOOD | ||||||||
State: | AZ | ||||||||
PostalCode: | 863263754 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286395580 | ||||||||
FaxNumber: | 9286395641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2016 | ||||||||
LastUpdateDate: | 09/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-2322 | AZ | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.