Provider Demographics
NPI:1649415209
Name:CLARK, VICKI LYNN (RN, LSW)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, LSW
Other - Prefix:MRS
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, LSW
Mailing Address - Street 1:13111 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-8732
Mailing Address - Country:US
Mailing Address - Phone:937-833-4388
Mailing Address - Fax:
Practice Address - Street 1:13111 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-8732
Practice Address - Country:US
Practice Address - Phone:937-833-4388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0028386104100000X
OHRN 185313163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No163W00000XNursing Service ProvidersRegistered Nurse