Provider Demographics
NPI:1376288837
Name:CLARK, NICHOLAS RICHARD (MA, MT-BC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RICHARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:MA, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N NEW ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2713
Mailing Address - Country:US
Mailing Address - Phone:484-735-3123
Mailing Address - Fax:
Practice Address - Street 1:911 N NEW ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-2713
Practice Address - Country:US
Practice Address - Phone:484-735-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15236225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist