Provider Demographics
NPI:1962836387
Name:CLARK, ANDREA KATHLEEN (LMSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:KATHLEEN
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 1:200 MAINE ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-1396
Mailing Address - Country:US
Mailing Address - Phone:785-843-9192
Mailing Address - Fax:785-843-6744
Practice Address - Street 1:200 MAINE ST STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1396
Practice Address - Country:US
Practice Address - Phone:785-843-9192
Practice Address - Fax:785-843-6744
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8885104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1841281805OtherCENTER NPI