Provider Demographics
NPI:1164539516
Name:CLARK, CARY LEONARD SR (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:LEONARD
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132
Mailing Address - Country:US
Mailing Address - Phone:817-782-1006
Mailing Address - Fax:817-737-7484
Practice Address - Street 1:6461 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-782-1006
Practice Address - Fax:817-737-7484
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8755101Y00000X
TX1321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453710001208Medicaid