Provider Demographics
NPI:1023214707
Name:CLARK, BRYN (LAC, DIPLOM)
Entity Type:Individual
Prefix:MR
First Name:BRYN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAC, DIPLOM
Other - Prefix:
Other - First Name:BRYN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:7 THORNDIKE ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-5817
Mailing Address - Country:US
Mailing Address - Phone:978-922-3030
Mailing Address - Fax:978-922-3086
Practice Address - Street 1:7 THORNDIKE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5817
Practice Address - Country:US
Practice Address - Phone:978-922-3030
Practice Address - Fax:978-922-3086
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213805171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist