Provider Demographics
NPI:1205079845
Name:GREEN, CLARK WILLIAM
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:WILLIAM
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11860 PORTAGE CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3100
Mailing Address - Country:US
Mailing Address - Phone:907-444-7859
Mailing Address - Fax:
Practice Address - Street 1:ANCHORAGE COMMUNITY MENTAL HEALTH 4020 FOLKER STREET
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-762-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical