Provider Demographics
NPI:1497376958
Name:CLARK, KEVIN P SR (LCSW-R)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HARRIMAN DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-2410
Mailing Address - Country:US
Mailing Address - Phone:845-291-2142
Mailing Address - Fax:
Practice Address - Street 1:30 HARRIMAN DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-2410
Practice Address - Country:US
Practice Address - Phone:845-291-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-049202-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical