Provider Demographics
NPI:1578153839
Name:CLARK, JOSHUA MICHAEL
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-3514
Mailing Address - Country:US
Mailing Address - Phone:315-730-1085
Mailing Address - Fax:
Practice Address - Street 1:380 FREEVILLE RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-9684
Practice Address - Country:US
Practice Address - Phone:607-844-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00353562Medicaid