Mary Watson Clark, LICSW, LMSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

21255 Issued in MN

Practice address

410 Church St SE
Minneapolis, MN 55455-0222

Phone

(612) 625-8400

Fax

(612) 677-3211

NPI assigned

Feb 5, 2007

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Regents of the University of Minnesota

  dba Community-University Health Care Center

  • Federally Qualified Health Center (FQHC)
  • Minneapolis, MN
  • NPI 1114019858
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170633600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1767052800000",
    "number": "1720127988",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "410 CHURCH ST SE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554550222",
            "telephone_number": "612-625-8400",
            "fax_number": "612-677-3211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 CHURCH ST SE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554550222",
            "telephone_number": "612-625-8400",
            "fax_number": "612-677-3211"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "MARY",
        "middle_name": "WATSON",
        "credential": "LICSW, LMSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-02-05",
        "last_updated": "2025-12-30",
        "certification_date": "2025-12-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MI",
            "license": "6801066900",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "MI",
            "license": "6801066900",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "21255",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Holly Diane Clark, LICSW
• Howard Brent Clark, M.D.
• Jennifer Clark
• Jennifer Anna Clark, RD, LD
• John Louis Clark, MD
• Megan Elizabeth Clark, RN
• Mekka Clark
• Monique Clark, RPH
• Nicholas Clark
• Nina Clark

• Clinical Social Worker in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.