Provider Demographics
NPI:1285031971
Name:LACROIX-CLARK, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:LACROIX-CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1616
Mailing Address - Country:US
Mailing Address - Phone:413-967-6241
Mailing Address - Fax:
Practice Address - Street 1:96 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1616
Practice Address - Country:US
Practice Address - Phone:413-967-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid