Provider Demographics
NPI:1609197235
Name:CLARK, KEELY (MSW, P-LCSW)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW, P-LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 759194
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9194
Mailing Address - Country:US
Mailing Address - Phone:540-710-6085
Mailing Address - Fax:540-710-6447
Practice Address - Street 1:1316 PATTON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-2666
Practice Address - Country:US
Practice Address - Phone:828-225-3100
Practice Address - Fax:828-225-3604
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0057831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical