Provider Demographics
NPI:1801806583
Name:CLARK, LINDA J (LCSW)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:J
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 1:238 N 2ND ST
Mailing Address - Street 2:STE.1
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1484
Mailing Address - Country:US
Mailing Address - Phone:859-623-0925
Mailing Address - Fax:859-625-9984
Practice Address - Street 1:238 N 2ND ST
Practice Address - Street 2:STE.1
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1484
Practice Address - Country:US
Practice Address - Phone:859-623-0925
Practice Address - Fax:859-625-9984
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-4321041C0700X
KYKY-0376106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY82004326Medicaid
000000042964OtherANTHEM
000000042964OtherANTHEM