Basic Information
| Provider Information | |||||||||
| NPI: | 1841648045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5101 E. US 36 HWY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462316646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | 3177459565 | ||||||||
| Practice Location | |||||||||
| Address1: | 5638 PROFESSIONAL CIR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462415042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | 3172478935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2016 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.