Basic Information
| Provider Information | |||||||||
| NPI: | 1487329173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANGELICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W OTIS AVE | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674018713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858250541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4155 E HARRY ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672183725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858250541 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 12255 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.