Provider Demographics
NPI:1255820569
Name:CLARK, BRENDA (LSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2662 WINTERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-7836
Mailing Address - Country:US
Mailing Address - Phone:330-357-6797
Mailing Address - Fax:
Practice Address - Street 1:4641 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2384
Practice Address - Country:US
Practice Address - Phone:330-433-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker