Provider Demographics
NPI:1477643518
Name:CLARK, PAUL A (LSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5007
Mailing Address - Country:US
Mailing Address - Phone:701-857-4232
Mailing Address - Fax:701-852-1190
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703
Practice Address - Country:US
Practice Address - Phone:701-854-4232
Practice Address - Fax:701-852-1190
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3915104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND74017Medicaid
ND26354OtherBLUE SHIELD