Provider Demographics
NPI:1740752260
Name:CLARK, ERIC DELANCEY
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DELANCEY
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2012
Mailing Address - Country:US
Mailing Address - Phone:617-708-0870
Mailing Address - Fax:
Practice Address - Street 1:12 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-2012
Practice Address - Country:US
Practice Address - Phone:617-708-0870
Practice Address - Fax:617-516-8274
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker