Basic Information
| Provider Information | |||||||||
| NPI: | 1992894992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 SUMMERBROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045251073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 GROSSCUP AVE | ||||||||
| Address2: | |||||||||
| City: | DUNBAR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250643128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045251073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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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 | AP00941076 | WV | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 1704 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | AP00941076 | 01 | WV | LSW | OTHER | 1704 | 01 | WV | LPC | OTHER |