Provider Demographics
NPI:1497823116
Name:CLARK, JULIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC100861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433835799Medicaid
MEE400171652Medicare PIN
001499401Medicare PIN