Provider Demographics
NPI:1043851934
Name:CLARK, LAQUITA M (BSW)
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:LAQUITA
Other - Middle Name:M
Other - Last Name:CLARK-LEWIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSW
Mailing Address - Street 1:209 W WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-1866
Mailing Address - Country:US
Mailing Address - Phone:330-787-9180
Mailing Address - Fax:
Practice Address - Street 1:209 W WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1866
Practice Address - Country:US
Practice Address - Phone:330-787-9180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health