Provider Demographics
NPI:1558847343
Name:CLARK, CORAL JUNE (MS, LSW)
Entity Type:Individual
Prefix:MS
First Name:CORAL
Middle Name:JUNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 MULLER AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-3444
Mailing Address - Country:US
Mailing Address - Phone:732-770-0019
Mailing Address - Fax:
Practice Address - Street 1:1500 ROUTE 88 W
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2320
Practice Address - Country:US
Practice Address - Phone:732-785-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06366100104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker