Provider Demographics
NPI:1417353996
Name:CLARK, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 BLOOMFIELD AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2700
Mailing Address - Country:US
Mailing Address - Phone:860-607-3235
Mailing Address - Fax:860-607-3201
Practice Address - Street 1:360 BLOOMFIELD AVE
Practice Address - Street 2:STE 301
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2700
Practice Address - Country:US
Practice Address - Phone:860-607-3235
Practice Address - Fax:860-607-3201
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional