Provider Demographics
NPI:1598839755
Name:CLARK, RICHARD JOSEPH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2312 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1600
Mailing Address - Country:US
Mailing Address - Phone:262-522-8512
Mailing Address - Fax:262-244-0914
Practice Address - Street 1:6700 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3919
Practice Address - Country:US
Practice Address - Phone:414-351-0450
Practice Address - Fax:414-351-8845
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1893057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical