Provider Demographics
NPI:1093019762
Name:CLARK, NICOLE (APSW, CSAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 N. BREMEN ST.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53121
Mailing Address - Country:US
Mailing Address - Phone:414-977-1200
Mailing Address - Fax:414-962-2305
Practice Address - Street 1:2618 N BREMEN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3003
Practice Address - Country:US
Practice Address - Phone:414-977-1200
Practice Address - Fax:414-962-2305
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129325-121104100000X
WI15777-132104100000X
WISACIT 15578-130104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker