Provider Demographics
NPI:1093953325
Name:CLARK, REBEKAH ANN (LPHA,LCSW)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPHA,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6106
Mailing Address - Country:US
Mailing Address - Phone:309-779-2031
Mailing Address - Fax:309-779-2027
Practice Address - Street 1:4600 3RD ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6106
Practice Address - Country:US
Practice Address - Phone:309-779-2031
Practice Address - Fax:309-779-2027
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490133491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208833004Medicare PIN