Provider Demographics
NPI:1073607552
Name:CLARK, VIRGINIA C (PHD, LCSW, RN, CAP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, LCSW, RN, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 SW 142ND STREET RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-5637
Mailing Address - Country:US
Mailing Address - Phone:352-233-7200
Mailing Address - Fax:
Practice Address - Street 1:4326 SW 142ND STREET RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-5637
Practice Address - Country:US
Practice Address - Phone:352-233-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW41461041C0700X
FLRN1646792163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL130-32-4646Medicare UPIN
FLZ7164Medicare ID - Type UnspecifiedLCSW
FL13-4133630Medicare UPIN