Provider Demographics
NPI:1083632491
Name:CLARK, MAURA TUKEY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:TUKEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 HATCH RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-3663
Mailing Address - Country:US
Mailing Address - Phone:207-926-5021
Mailing Address - Fax:
Practice Address - Street 1:180 HATCH RD
Practice Address - Street 2:
Practice Address - City:NEW GLOUCESTER
Practice Address - State:ME
Practice Address - Zip Code:04260-3663
Practice Address - Country:US
Practice Address - Phone:207-926-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC110881041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA31686OtherHEALTH NEW ENGLAND