Provider Demographics
NPI:1629491071
Name:CLARK, RALPH M (CASAC)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4000
Mailing Address - Country:US
Mailing Address - Phone:516-747-5644
Mailing Address - Fax:516-747-2556
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4000
Practice Address - Country:US
Practice Address - Phone:516-747-5644
Practice Address - Fax:516-747-2556
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3827101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)