Provider Demographics
NPI:1225262710
Name:CLARK, BETTY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 155
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-864-2520
Mailing Address - Fax:254-526-7853
Practice Address - Street 1:205 E UNIVERSITY AVE
Practice Address - Street 2:SUITE 155
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-6814
Practice Address - Country:US
Practice Address - Phone:512-864-2520
Practice Address - Fax:254-526-7853
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25588103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical