Provider Demographics
NPI:1447287453
Name:CLARK, BRIAN KEITH (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4425
Mailing Address - Country:US
Mailing Address - Phone:425-349-7447
Mailing Address - Fax:425-349-7339
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-349-7447
Practice Address - Fax:425-349-7339
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000064151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical