Provider Demographics
NPI:1881754109
Name:CLARK, SUSAN (LCSW-S)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N BRITAIN RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-4559
Mailing Address - Country:US
Mailing Address - Phone:214-395-7094
Mailing Address - Fax:
Practice Address - Street 1:1650 W MAGNOLIA AVE
Practice Address - Street 2:208
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4009
Practice Address - Country:US
Practice Address - Phone:817-912-8006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX500381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1881754109Medicaid