Provider Demographics
NPI:1609944693
Name:CLARK, CHRISTOPHER BRUCE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:BRUCE
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2504
Mailing Address - Country:US
Mailing Address - Phone:414-427-5310
Mailing Address - Fax:414-427-5311
Practice Address - Street 1:4455 S 108TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2504
Practice Address - Country:US
Practice Address - Phone:414-427-5310
Practice Address - Fax:414-427-5311
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI80971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609944693Medicaid