Provider Demographics
NPI:1568628535
Name:CLARK, KATHRYN LEIGH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:LEIGH
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1554
Mailing Address - Country:US
Mailing Address - Phone:718-623-9125
Mailing Address - Fax:
Practice Address - Street 1:100 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1554
Practice Address - Country:US
Practice Address - Phone:718-623-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012553-1103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent