Provider Demographics
NPI:1851875207
Name:CLARK, REBECCA SUE (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 E FAIR ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-3558
Mailing Address - Country:US
Mailing Address - Phone:719-289-8743
Mailing Address - Fax:
Practice Address - Street 1:201 E LAUREL ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5538
Practice Address - Country:US
Practice Address - Phone:620-272-9506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10958104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker