Provider Demographics
NPI:1164417424
Name:CLARK-DOOLITTLE ASSOC PC
Entity Type:Organization
Organization Name:CLARK-DOOLITTLE ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-547-7292
Mailing Address - Street 1:71 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-2414
Mailing Address - Country:US
Mailing Address - Phone:617-547-7292
Mailing Address - Fax:802-763-2182
Practice Address - Street 1:71 WALKER ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-2414
Practice Address - Country:US
Practice Address - Phone:617-547-7292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900005591041C0700X
MA1010571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOUN2222Medicaid
CLUN2222Medicare UPIN
VTOUN2222Medicaid