Provider Demographics
NPI:1437876844
Name:CLARK, SHEILA (LCDCIII)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33275 AMBLESIDE DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2381
Mailing Address - Country:US
Mailing Address - Phone:440-263-7657
Mailing Address - Fax:
Practice Address - Street 1:4901 TURNEY RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2546
Practice Address - Country:US
Practice Address - Phone:216-633-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0009439Medicaid