Provider Demographics
NPI:1043944135
Name:DANIEL CLARK PHD LLC
Entity Type:Organization
Organization Name:DANIEL CLARK PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-230-9561
Mailing Address - Street 1:483 BEACON ST PH 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1336
Mailing Address - Country:US
Mailing Address - Phone:801-230-9561
Mailing Address - Fax:
Practice Address - Street 1:483 BEACON ST PH 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-1336
Practice Address - Country:US
Practice Address - Phone:801-230-9561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty