Provider Demographics
NPI:1205845336
Name:CLARK, BRIAN K (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:K
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:#103
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132
Practice Address - Country:US
Practice Address - Phone:414-425-1250
Practice Address - Fax:414-425-1459
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1471-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39235600Medicaid