Provider Demographics
NPI:1184220725
Name:CLARK, TORI P (LICSW)
Entity type:Individual
Prefix:
First Name:TORI
Middle Name:P
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TORI
Other - Middle Name:P
Other - Last Name:MAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:716 E ST NE
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2857
Mailing Address - Country:US
Mailing Address - Phone:218-828-7379
Mailing Address - Fax:218-828-7390
Practice Address - Street 1:716 E ST NE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2857
Practice Address - Country:US
Practice Address - Phone:218-828-7379
Practice Address - Fax:218-828-7390
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN272291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical