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Individual

BENJAMIN CLARK

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
LMSW

Contact information

Practice address
1727 N OCEAN AVE, MEDFORD, NY 11763-2649
(631) 654-1919
Mailing address
121 GLENMERE WAY, HOLBROOK, NY 11741-5013
(631) 654-1919

Taxonomy

Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
078914-1
NY

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
078914-1
LICENSE
NY
Enumeration date
06/09/2010
Last updated
06/09/2010
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