Provider Demographics
NPI:1366107518
Name:CLARK, ELIZABETH ELLEN (MSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1654
Mailing Address - Country:US
Mailing Address - Phone:740-357-8615
Mailing Address - Fax:
Practice Address - Street 1:419 VERNON ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1637
Practice Address - Country:US
Practice Address - Phone:740-357-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHS.2308966104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker