Provider Demographics
NPI:1619268422
Name:CLARK, SUSAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 E BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1037
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2013-007106H00000X
KY50491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist