Provider Demographics
NPI:1033666417
Name:CLARK, CHRISTINE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1623
Mailing Address - Country:US
Mailing Address - Phone:612-223-8899
Mailing Address - Fax:
Practice Address - Street 1:7601 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1623
Practice Address - Country:US
Practice Address - Phone:612-223-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6417103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist