Provider Demographics
NPI:1780571703
Name:CLARK, SAMUEL S
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:S
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 1:1942 STEWART AVE APT G20
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-2513
Mailing Address - Country:US
Mailing Address - Phone:785-410-4389
Mailing Address - Fax:
Practice Address - Street 1:1511 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-4307
Practice Address - Country:US
Practice Address - Phone:913-349-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional