Provider Demographics
NPI:1952053928
Name:CLARK, ROGER DAN JR (LMSW)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DAN
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 S BRAESWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-3392
Mailing Address - Country:US
Mailing Address - Phone:713-986-7835
Mailing Address - Fax:
Practice Address - Street 1:4131 S BRAESWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-3392
Practice Address - Country:US
Practice Address - Phone:713-986-7835
Practice Address - Fax:713-667-3619
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69670104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker