Provider Demographics
NPI:1366922684
Name:CLARK, RICHARD SHELDON
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:SHELDON
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:S
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:311 PENNY DR
Mailing Address - Street 2:
Mailing Address - City:LITHOPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:43136-9704
Mailing Address - Country:US
Mailing Address - Phone:614-592-8385
Mailing Address - Fax:
Practice Address - Street 1:311 PENNY DR
Practice Address - Street 2:
Practice Address - City:LITHOPOLIS
Practice Address - State:OH
Practice Address - Zip Code:43136-9704
Practice Address - Country:US
Practice Address - Phone:614-592-8385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH14304331Medicaid