Provider Demographics
NPI:1659468437
Name:CLARK, MARY BRADFORD (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRADFORD
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2497 7TH AVE E
Mailing Address - Street 2:SUITE 101 C/O BHSI LLC
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2496
Mailing Address - Country:US
Mailing Address - Phone:651-769-6437
Mailing Address - Fax:651-769-6426
Practice Address - Street 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 304 BHSI LLC
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4344
Practice Address - Country:US
Practice Address - Phone:651-769-6250
Practice Address - Fax:651-769-6299
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN173111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical