Provider Demographics
NPI:1275614083
Name:CLARK, DAVID B (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16216 BAXTER RD
Mailing Address - Street 2:SUITE 323
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4770
Mailing Address - Country:US
Mailing Address - Phone:636-537-8222
Mailing Address - Fax:636-537-8223
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:SUITE 323
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4770
Practice Address - Country:US
Practice Address - Phone:636-537-8222
Practice Address - Fax:636-537-8223
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00939103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4858Medicare UPIN