Provider Demographics
NPI:1740879535
Name:CLARK, ELLA (CM/SC)
Entity type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CM/SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BURKE RD
Mailing Address - Street 2:
Mailing Address - City:DELBARTON
Mailing Address - State:WV
Mailing Address - Zip Code:25670-6041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 BURKE RD
Practice Address - Street 2:
Practice Address - City:DELBARTON
Practice Address - State:WV
Practice Address - Zip Code:25670-6041
Practice Address - Country:US
Practice Address - Phone:304-444-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator