Provider Demographics
NPI:1568566917
Name:CLARK, DERRICK J (PHD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:J
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 1:1663 DOMINICAN WAY
Mailing Address - Street 2:STE 214
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1527
Mailing Address - Country:US
Mailing Address - Phone:831-475-3231
Mailing Address - Fax:831-462-4936
Practice Address - Street 1:1663 DOMINICAN WAY
Practice Address - Street 2:STE 214
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1527
Practice Address - Country:US
Practice Address - Phone:831-475-3231
Practice Address - Fax:831-462-4936
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13424103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY134241Medicaid
CAPSY134241Medicaid