Provider Demographics
NPI:1497895460
Name:CLARK, GAIL M (LPCMH)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 WILMAS WAY
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-5538
Mailing Address - Country:US
Mailing Address - Phone:302-604-3906
Mailing Address - Fax:
Practice Address - Street 1:278 WILMAS WAY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-5538
Practice Address - Country:US
Practice Address - Phone:302-604-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
DEPC-0000366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000040998Medicaid