Provider Demographics
NPI:1407174998
Name:CLARK, PETER A (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WATER ST STE 306
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901
Mailing Address - Country:US
Mailing Address - Phone:207-861-6200
Mailing Address - Fax:207-861-3470
Practice Address - Street 1:10 WATER ST STE 306
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6566
Practice Address - Country:US
Practice Address - Phone:207-861-6200
Practice Address - Fax:207-861-3470
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC124151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical