Provider Demographics
NPI:1932561115
Name:CLARK, BRANDON W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3947
Mailing Address - Country:US
Mailing Address - Phone:208-717-4453
Mailing Address - Fax:855-564-1778
Practice Address - Street 1:0309 2ND ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2163
Practice Address - Country:US
Practice Address - Phone:208-717-4453
Practice Address - Fax:855-564-1778
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW610859801041C0700X
IDLCSW 353561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical