Provider Demographics
NPI:1831103522
Name:CLARK, TRACY L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HEMPHILL PLACE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4423
Mailing Address - Country:US
Mailing Address - Phone:518-289-5072
Mailing Address - Fax:518-289-5225
Practice Address - Street 1:5 HEMPHILL PLACE
Practice Address - Street 2:SUITE 121
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4423
Practice Address - Country:US
Practice Address - Phone:518-289-5072
Practice Address - Fax:518-289-5225
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0692421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY069242Medicaid
040426031952OtherFIDELIS
53088OtherMVP
CC8684Medicare ID - Type Unspecified
040426031952OtherFIDELIS
P56824Medicare UPIN