Provider Demographics
NPI:1235771031
Name:CLACK ASSOCIATES, LLC.
Entity Type:Organization
Organization Name:CLACK ASSOCIATES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-596-3196
Mailing Address - Street 1:200 DAVISTOWN ROAD PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-9998
Mailing Address - Country:US
Mailing Address - Phone:856-875-5335
Mailing Address - Fax:
Practice Address - Street 1:603 LIBERTY PLACE
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081
Practice Address - Country:US
Practice Address - Phone:856-875-5335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty