Provider Demographics
NPI:1457834061
Name:CLARK, CARLEY MARIE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:MARIE
Other - Last Name:COLLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-8010
Practice Address - Street 1:1600 SPECHT POINT RD STE 105
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4311
Practice Address - Country:US
Practice Address - Phone:970-494-5891
Practice Address - Fax:970-494-5885
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CO0009924642104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator