Provider Demographics
NPI:1689608952
Name:CLARK, GREGORY D (MSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:118 BROADWAY N
Mailing Address - Street 2:STE 810
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4949
Mailing Address - Country:US
Mailing Address - Phone:701-799-8785
Mailing Address - Fax:701-205-4930
Practice Address - Street 1:118 BROADWAY N
Practice Address - Street 2:STE 810
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4949
Practice Address - Country:US
Practice Address - Phone:701-799-8785
Practice Address - Fax:701-205-4930
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NDLICSW 29731041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND015066OtherBCBS OF ND PIN
MN03Q32CLOtherBCBS OF MN PIN
MN03Q32CLOtherBCBS OF MN PIN