Provider Demographics
NPI:1225776131
Name:CLARK, SHANNICE T (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:SHANNICE
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 RAY NORRISH DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-1520
Mailing Address - Country:US
Mailing Address - Phone:513-802-5080
Mailing Address - Fax:
Practice Address - Street 1:432 RAY NORRISH DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-1520
Practice Address - Country:US
Practice Address - Phone:513-802-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1502424104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker