Provider Demographics
NPI:1245665363
Name:CLARK, RANDOLPH LAIRD (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:LAIRD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 PIT RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9555
Mailing Address - Country:US
Mailing Address - Phone:317-742-9400
Mailing Address - Fax:317-742-9414
Practice Address - Street 1:554 PIT RD
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-9555
Practice Address - Country:US
Practice Address - Phone:317-742-9400
Practice Address - Fax:317-742-9414
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007681A1041C0700X
IN33006610A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical