Provider Demographics
NPI:1417175936
Name:CLARK, RICHARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3866
Mailing Address - Country:US
Mailing Address - Phone:972-436-1411
Mailing Address - Fax:
Practice Address - Street 1:376 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3866
Practice Address - Country:US
Practice Address - Phone:972-436-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31729103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical