Provider Demographics
NPI:1700355468
Name:CLARK, JULIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 SPOTTED JACK LOOP N
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-6974
Mailing Address - Country:US
Mailing Address - Phone:406-696-2814
Mailing Address - Fax:
Practice Address - Street 1:3733 SPOTTED JACK LOOP N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-6974
Practice Address - Country:US
Practice Address - Phone:406-696-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-24
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT324331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-LCSW-LIC-32433Medicaid