Provider Information for 1558449843
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GREGORY JAMES CLARK LCSW-R
Sex: Male
NPI: 1558449843
Last Updated: 2007-07-08
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1558449843 | ||||||||
| Enumeration Date | 2006-11-02 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 2608 ROUTE 305 CUBA, NY 14727-9555 United States Phone: 585-968-3816 | Fax: | ||||||||
| Primary Practice Address | 2656 W STATE ST SUITE 506 OLEAN, NY 14760-1871 United States Phone: 716-378-1002 | Fax:716-373-2170 | ||||||||
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