Provider Demographics
NPI:1366597957
Name:CLARK, CATHLEEN ANN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:CATHLEEN
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16
Mailing Address - Street 2:
Mailing Address - City:LECLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753
Mailing Address - Country:US
Mailing Address - Phone:563-289-4748
Mailing Address - Fax:
Practice Address - Street 1:1706 N BRADY
Practice Address - Street 2:SUITE 204
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803
Practice Address - Country:US
Practice Address - Phone:563-650-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03801104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker