Provider Demographics
NPI:1851617443
Name:CLARK, SALLY A (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:A
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 1:109 FORD ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1419
Mailing Address - Country:US
Mailing Address - Phone:315-394-0101
Mailing Address - Fax:315-394-0097
Practice Address - Street 1:109 FORD ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1419
Practice Address - Country:US
Practice Address - Phone:315-394-0101
Practice Address - Fax:315-394-0097
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038215-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical