Provider Demographics
NPI:1720201098
Name:CLARK, KATHLEEN S (LSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 150TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-8125
Mailing Address - Country:US
Mailing Address - Phone:715-646-2033
Mailing Address - Fax:
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE 50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8415
Practice Address - Fax:715-485-8490
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1555 120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator