Provider Demographics
NPI:1841927415
Name:CLARK, NICOLE RENAE (LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 27TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:CENTER POINT
Mailing Address - State:AL
Mailing Address - Zip Code:35215-2216
Mailing Address - Country:US
Mailing Address - Phone:205-482-2739
Mailing Address - Fax:
Practice Address - Street 1:48 MEDICAL PARK DR E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3400
Practice Address - Country:US
Practice Address - Phone:205-517-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3619C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical