Provider Demographics
NPI:1720636160
Name:CLARK WEBSTER, MARY ALYCE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALYCE
Last Name:CLARK WEBSTER
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 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4124
Mailing Address - Country:US
Mailing Address - Phone:143-447-2000
Mailing Address - Fax:413-447-2176
Practice Address - Street 1:725 NORTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4109
Practice Address - Country:US
Practice Address - Phone:413-447-2000
Practice Address - Fax:413-447-2176
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA09040136611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician