Provider Demographics
NPI:1730661414
Name:CLARK, BRITTANY JOYELL (BSW)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:JOYELL
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1508
Mailing Address - Country:US
Mailing Address - Phone:607-664-2255
Mailing Address - Fax:
Practice Address - Street 1:115 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1508
Practice Address - Country:US
Practice Address - Phone:607-664-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-6002567Medicaid