Provider Demographics
NPI:1740262633
Name:CLARK, REBECCA (BECKY) A (PHD, LCSW-R, CC-AASP)
Entity type:Individual
Prefix:DR
First Name:REBECCA (BECKY)
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, LCSW-R, CC-AASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 RIVERSIDE DR
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3726
Mailing Address - Country:US
Mailing Address - Phone:917-733-5483
Mailing Address - Fax:
Practice Address - Street 1:125 RIVERSIDE DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3726
Practice Address - Country:US
Practice Address - Phone:917-733-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0379541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN263X1Medicare ID - Type Unspecified