Provider Demographics
NPI:1972633253
Name:CLARK, SUE ANN SR (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:ANN
Last Name:CLARK
Suffix:SR
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 W STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-5007
Mailing Address - Country:US
Mailing Address - Phone:815-235-7076
Mailing Address - Fax:
Practice Address - Street 1:717 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5007
Practice Address - Country:US
Practice Address - Phone:815-235-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical