Provider Demographics
NPI:1437394103
Name:CLARK PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:CLARK PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:334-300-7021
Mailing Address - Street 1:9571 WINFIELD PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-5157
Mailing Address - Country:US
Mailing Address - Phone:334-300-7021
Mailing Address - Fax:
Practice Address - Street 1:3196 PARLIAMENT CIRCLE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-0000
Practice Address - Country:US
Practice Address - Phone:334-300-7021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1076103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225093891OtherNPI - PERSONAL ISSUED TO DR. CLARK