Provider Demographics
NPI:1558449843
Name:CLARK, GREGORY JAMES (LCSW-R)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:CLARK
Suffix:
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 1:2608 ROUTE 305
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:NY
Mailing Address - Zip Code:14727-9555
Mailing Address - Country:US
Mailing Address - Phone:585-968-3816
Mailing Address - Fax:
Practice Address - Street 1:2656 W STATE ST
Practice Address - Street 2:SUITE 506
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1871
Practice Address - Country:US
Practice Address - Phone:716-378-1002
Practice Address - Fax:716-373-2170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR073675-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000590314001OtherBLUE CROSS BLUE SHIELD