Provider Demographics
NPI:1164473245
Name:CLARK, GAIL E (LCSW)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:E
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11644 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4010
Mailing Address - Country:US
Mailing Address - Phone:727-391-7359
Mailing Address - Fax:
Practice Address - Street 1:4024 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW81761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical