Provider Demographics
NPI:1609896943
Name:CLARK, DEBRA JEAN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARKET ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2655
Mailing Address - Country:US
Mailing Address - Phone:607-432-1914
Mailing Address - Fax:
Practice Address - Street 1:10 MARKET ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2655
Practice Address - Country:US
Practice Address - Phone:607-432-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058000-1101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11662733OtherCAQH NUMBER
NYIA1281Medicare PIN