1710376264 NPI number — MS. KATELYN ELIZABETH CLARK LMSW

Table of content: MS. KATELYN ELIZABETH CLARK LMSW (NPI 1710376264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710376264 NPI number — MS. KATELYN ELIZABETH CLARK LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
KATELYN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
KATELYN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710376264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1978
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21802-1978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-749-1015
Provider Business Mailing Address Fax Number:
410-749-0654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9958 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21811-1077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-973-2820
Provider Business Practice Location Address Fax Number:
410-973-2843
Provider Enumeration Date:
01/21/2015

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: 104100000X , with the licence number:  24983 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119591300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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