Provider Demographics
NPI:1003284274
Name:THOMPSON, CLARK ROBERT (MA)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:ROBERT
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3006
Mailing Address - Country:US
Mailing Address - Phone:847-441-5600
Mailing Address - Fax:
Practice Address - Street 1:86 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1822
Practice Address - Country:US
Practice Address - Phone:479-435-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1810AP-PL103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist