Provider Demographics
NPI:1477032175
Name:CLARK, MIRANDA LYNN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 E HAWLEY RD
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01339-9610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 EAST HAWLEY RD
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MA
Practice Address - Zip Code:01339
Practice Address - Country:US
Practice Address - Phone:413-475-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE