Provider Demographics
NPI:1376517045
Name:CLARK, MONICA MARY (MSW LISW LMFT)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:MARY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW LISW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 EAST 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-4049
Mailing Address - Fax:563-359-4069
Practice Address - Street 1:2102 EAST 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:563-359-4069
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08211041C0700X
IA16106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1108750000Medicaid
IA1108750000Medicaid
IAI12733Medicare UPIN