Provider Demographics
NPI:1023797974
Name:CLARK, EARLINE MAYS (BSW)
Entity type:Individual
Prefix:MRS
First Name:EARLINE
Middle Name:MAYS
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:EARLINE
Other - Middle Name:MAYS
Other - Last Name:ACOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW - EARLINE ACOFF
Mailing Address - Street 1:2219 CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4301
Mailing Address - Country:US
Mailing Address - Phone:318-779-0434
Mailing Address - Fax:
Practice Address - Street 1:2219 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4301
Practice Address - Country:US
Practice Address - Phone:318-779-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty