Provider Demographics
NPI:1508339524
Name:CLARK INSTITUTE PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:CLARK INSTITUTE PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-204-5589
Mailing Address - Street 1:7150 KALAMAZOO AVE SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316
Mailing Address - Country:US
Mailing Address - Phone:616-219-0159
Mailing Address - Fax:616-219-0124
Practice Address - Street 1:7150 KALAMAZOO AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316
Practice Address - Country:US
Practice Address - Phone:616-219-0159
Practice Address - Fax:616-219-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty