Provider Demographics
NPI:1609625136
Name:VAN DEN BERK-CLARK, CARISSA J (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:J
Last Name:VAN DEN BERK-CLARK
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 S SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-4840
Mailing Address - Fax:
Practice Address - Street 1:805 SAINT FRANCIS WAY
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1779
Practice Address - Country:US
Practice Address - Phone:217-250-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220150611041C0700X
IL150.1037681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical