Basic Information
| Provider Information | |||||||||
| NPI: | 1386142750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6057 DANA RD SW | ||||||||
| Address2: | |||||||||
| City: | SHERRODSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446759778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037052072 | ||||||||
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| Practice Location | |||||||||
| Address1: | 919 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304547917 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2018 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.