Provider Demographics
NPI:1669865804
Name:CLARKE, BETH S (LCSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:S
Last Name:CLARKE
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:PO BOX 7736
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04112-7736
Mailing Address - Country:US
Mailing Address - Phone:207-274-3928
Mailing Address - Fax:
Practice Address - Street 1:400 CONGRESS ST
Practice Address - Street 2:#7736
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04112-3500
Practice Address - Country:US
Practice Address - Phone:207-274-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC163541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical