Provider Demographics
NPI:1144600800
Name:GREGORY D. CLARK, MSW, LLC
Entity Type:Organization
Organization Name:GREGORY D. CLARK, MSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DARWIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:701-799-8785
Mailing Address - Street 1:118 BROADWAY N
Mailing Address - Street 2:SUITE 810
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4949
Mailing Address - Country:US
Mailing Address - Phone:701-799-8785
Mailing Address - Fax:701-205-4930
Practice Address - Street 1:118 BROADWAY N
Practice Address - Street 2:SUITE 810
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4949
Practice Address - Country:US
Practice Address - Phone:701-799-8785
Practice Address - Fax:701-205-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty