Provider Demographics
NPI:1649506833
Name:CLARK, KIMBERLY S (LISW-S)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2903
Mailing Address - Country:US
Mailing Address - Phone:330-343-7605
Mailing Address - Fax:330-343-3542
Practice Address - Street 1:201 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2903
Practice Address - Country:US
Practice Address - Phone:330-343-7605
Practice Address - Fax:330-343-3542
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00071911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical