Provider Demographics
NPI:1851898233
Name:CLARK, AMY (LCSW, SAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W LOOMIS RD STE 217
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8887
Mailing Address - Country:US
Mailing Address - Phone:414-773-4312
Mailing Address - Fax:
Practice Address - Street 1:9200 W LOOMIS RD STE 217
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132
Practice Address - Country:US
Practice Address - Phone:414-773-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16182-132101YA0400X
WI8789-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)