Provider Demographics
NPI:1043463201
Name:CLARK, LEILA SUZANNE (LMSW, LPN)
Entity Type:Individual
Prefix:MS
First Name:LEILA
Middle Name:SUZANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HILL 99
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1424
Mailing Address - Country:US
Mailing Address - Phone:845-594-7034
Mailing Address - Fax:
Practice Address - Street 1:21 HILL 99
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-1424
Practice Address - Country:US
Practice Address - Phone:845-594-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258103-1164W00000X
NY099205-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No164W00000XNursing Service ProvidersLicensed Practical Nurse