Provider Demographics
NPI:1336429414
Name:CLARK, DEIRDRE DANIELLE (MSW)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:DANIELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-1366
Mailing Address - Country:US
Mailing Address - Phone:850-769-6001
Mailing Address - Fax:850-769-6003
Practice Address - Street 1:2844 HAMPTON MEADOW DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-8124
Practice Address - Country:US
Practice Address - Phone:850-877-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator