Kelli Marie Clark
Individual provider Active NPI Clinical Social Worker · Massena, NY
NPI 1104196815 · NPPES record last updated Apr 24, 2018
Key facts
- NPI
- 1104196815
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Social Worker 1041C0700X
- License
- R054044-1 (NY)
- Practice address
- 23 Maple St
Massena, NY 13662-1017 - Phone
- (315) 769-8441
- NPI assigned
- Jan 11, 2012
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180223002093 | NY | Order and Referring Only - Clinical Social Worker | 0749541217 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R054044-1 | NY | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| St. Lawrence Psychiatric Center | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | R054044-1 | NY | Yes |
Addresses
Primary practice location
23 Maple St
Massena, NY 13662-1017
Mailing address
23 Maple St
Massena, NY 13662-1017
Other providers in Massena, NY
- Mona Chapman
- Kathryn Jane Chilton I
- Taesik Choi
- Joanne Wilson Cichetti
- Neil Joseph Cichetti
- Heather Lee Collins
- Pamela Marie Collins
- Lyndsi Comins
- Katie Congdon
- Katherine Cox
All providers in Massena, NY · Clinical Social Worker in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 24, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.