Provider Demographics
NPI:1356512149
Name:CLARK, STEPHANIE DENISE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 PAULDING AVE
Mailing Address - Street 2:APT. 1H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2151
Mailing Address - Country:US
Mailing Address - Phone:718-409-6481
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:ROOM 5B-07
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY080972-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)