Provider Demographics
NPI:1851644819
Name:CLARK, SUZANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
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 1:4408 DELWOOD LN
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7492
Mailing Address - Country:US
Mailing Address - Phone:850-866-5180
Mailing Address - Fax:
Practice Address - Street 1:4408 DELWOOD LN
Practice Address - Street 2:SUITE 4
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32408-7492
Practice Address - Country:US
Practice Address - Phone:850-866-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW106631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical