Provider Demographics
NPI:1609385335
Name:CLARK, LOUISE (CASAC)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 CONEY ISLAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5224
Mailing Address - Country:US
Mailing Address - Phone:718-265-4200
Mailing Address - Fax:
Practice Address - Street 1:3044 CONEY ISLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5224
Practice Address - Country:US
Practice Address - Phone:718-265-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18650101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)