Provider Demographics
NPI:1407866981
Name:CLARK, THOMAS R (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:CLARK
Suffix:
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 1:41820 6 MILE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-2763
Mailing Address - Country:US
Mailing Address - Phone:248-349-3131
Mailing Address - Fax:248-349-3232
Practice Address - Street 1:41820 6 MILE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-2763
Practice Address - Country:US
Practice Address - Phone:248-349-3131
Practice Address - Fax:248-349-3232
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001244103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical