Provider Demographics
NPI:1326359860
Name:CLARK, LORI ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ELLEN
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 1:9 JACOBS LN
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2654
Mailing Address - Country:US
Mailing Address - Phone:919-624-3338
Mailing Address - Fax:203-272-6968
Practice Address - Street 1:1095 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3432
Practice Address - Country:US
Practice Address - Phone:203-271-3809
Practice Address - Fax:203-272-6968
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3952103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral