Provider Demographics
NPI:1598813073
Name:CLARK, ALICE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-0458
Mailing Address - Country:US
Mailing Address - Phone:802-585-0297
Mailing Address - Fax:
Practice Address - Street 1:55 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1556
Practice Address - Country:US
Practice Address - Phone:802-585-0297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7094103TC0700X
VT048.0057921103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06Z86OtherBCBS
MAW06Z86OtherBCBS