Provider Demographics
NPI:1376015156
Name:TALBOTT-CLARK, BRYAN JEROME (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JEROME
Last Name:TALBOTT-CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:BRYAN
Other - Middle Name:JEROME
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 AMBASSADOR DR FL 4
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5922
Mailing Address - Country:US
Mailing Address - Phone:907-729-4558
Mailing Address - Fax:
Practice Address - Street 1:3900 AMBASSADOR DR FL 4
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5922
Practice Address - Country:US
Practice Address - Phone:907-729-4558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1230011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical