Provider Demographics
NPI:1841648045
Name:CLARK, EMILY MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
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 1:5101 E. US 36 HWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46231-6646
Mailing Address - Country:US
Mailing Address - Phone:888-714-1927
Mailing Address - Fax:317-745-9565
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5042
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-247-8935
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN34008960A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker