Provider Demographics
NPI:1508074311
Name:CLARK, KIM (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 LEONARD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROYALTON
Mailing Address - State:VT
Mailing Address - Zip Code:05068-9565
Mailing Address - Country:US
Mailing Address - Phone:802-763-8773
Mailing Address - Fax:
Practice Address - Street 1:226 LEONARD RD
Practice Address - Street 2:
Practice Address - City:SOUTH ROYALTON
Practice Address - State:VT
Practice Address - Zip Code:05068-9565
Practice Address - Country:US
Practice Address - Phone:802-763-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1010571041C0700X
VT08900005591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2222Medicaid
VTOVN2222Medicaid
VTCLVN2222Medicare UPIN