Provider Demographics
NPI:1164683272
Name:CLARK, EDNA K (LCSW)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1382
Mailing Address - Country:US
Mailing Address - Phone:865-500-2143
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:7744 CONNER RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3509
Practice Address - Country:US
Practice Address - Phone:865-546-9751
Practice Address - Fax:833-908-2167
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN78291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid