Provider Demographics
NPI:1629370739
Name:CLARKE, SANDRA RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:RAE
Last Name:CLARKE
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 1:6 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1480
Mailing Address - Country:US
Mailing Address - Phone:203-709-1543
Mailing Address - Fax:203-503-3296
Practice Address - Street 1:6 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1480
Practice Address - Country:US
Practice Address - Phone:203-709-1543
Practice Address - Fax:203-503-3296
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
CT0082441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid