1740276906 NPI number — KATHLEEN M. CLARK L.C.S.W. , B.C.D.

Table of content: KATHLEEN M. CLARK L.C.S.W. , B.C.D. (NPI 1740276906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740276906 NPI number — KATHLEEN M. CLARK L.C.S.W. , B.C.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
KATHLEEN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W. , B.C.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740276906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3724 JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78731-6221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-452-8948
Provider Business Mailing Address Fax Number:
512-452-0459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3724 JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731-6221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-452-8948
Provider Business Practice Location Address Fax Number:
512-452-0459
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  S03218 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 3218 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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