Provider Demographics
NPI:1659592962
Name:CLARK, SANDRA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:CLARK
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 1:2386 CLOWER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6134
Mailing Address - Country:US
Mailing Address - Phone:404-276-2310
Mailing Address - Fax:770-860-8315
Practice Address - Street 1:2386 CLOWER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6134
Practice Address - Country:US
Practice Address - Phone:404-276-2310
Practice Address - Fax:770-860-8315
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0024501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical