Provider Demographics
NPI:1922048180
Name:CLARK-BURCH, GRACE I (LCSW-R)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:I
Last Name:CLARK-BURCH
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 1:247 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-3825
Mailing Address - Country:US
Mailing Address - Phone:716-393-2905
Mailing Address - Fax:716-433-0100
Practice Address - Street 1:4711 TRANSIT RD
Practice Address - Street 2:SUITE 3 FORESTREAM VILLAGE
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4888
Practice Address - Country:US
Practice Address - Phone:716-706-5921
Practice Address - Fax:716-706-5923
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR076093-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA
NY000506354003OtherCOMMUNITY BLUE