Provider Demographics
NPI:1689039257
Name:CLARK, SAMANTHA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
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 1:7717 N ORANGE PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9323
Mailing Address - Country:US
Mailing Address - Phone:309-589-6800
Mailing Address - Fax:309-589-6973
Practice Address - Street 1:3117 1ST AVE SE STE A
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4403
Practice Address - Country:US
Practice Address - Phone:319-961-2609
Practice Address - Fax:319-365-0899
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0186751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical