Provider Demographics
NPI:1649380502
Name:WOOLDRIDGE, CLARK E JR (LISW ACP)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:E
Last Name:WOOLDRIDGE
Suffix:JR
Gender:M
Credentials:LISW ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3519 TRIPP
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79121
Mailing Address - Country:US
Mailing Address - Phone:806-359-4127
Mailing Address - Fax:806-359-4127
Practice Address - Street 1:1220 MITCHELL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:806-681-6745
Practice Address - Fax:505-742-3182
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI22671041C0700X
TX053391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97107Medicaid