Provider Demographics
NPI:1609013242
Name:CLARKE, WENDY L (LMSW/CC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LMSW/CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1200
Mailing Address - Fax:207-871-1235
Practice Address - Street 1:25 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-3531
Practice Address - Country:US
Practice Address - Phone:207-782-0079
Practice Address - Fax:207-782-2636
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC37791041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool