Provider Demographics
NPI:1821142480
Name:CLARK, ELAINE RUTHERFORD (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:RUTHERFORD
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 VILLAGE GREEN PKWY STE 4
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3401
Mailing Address - Country:US
Mailing Address - Phone:941-795-7025
Mailing Address - Fax:941-795-1480
Practice Address - Street 1:501 VILLAGE GREEN PKWY STE 4
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3401
Practice Address - Country:US
Practice Address - Phone:941-795-7025
Practice Address - Fax:941-795-1480
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00032791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5542Medicare ID - Type UnspecifiedLCSW