Basic Information
| Provider Information | |||||||||
| NPI: | 1316249675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MONICA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049764823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074748311 | ||||||||
| FaxNumber: | 2074748145 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2076604529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2010 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC14664 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.