Provider Demographics
NPI:1750058731
Name:CLARK, MARCUS (LCSW)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SHADOWMORE DR
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295-3607
Mailing Address - Country:US
Mailing Address - Phone:770-584-2393
Mailing Address - Fax:
Practice Address - Street 1:1070 COUNTY FARM ROAD
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295
Practice Address - Country:US
Practice Address - Phone:770-567-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0066751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical