Provider Demographics
NPI:1609934397
Name:CLARK, KEVIN JOHN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2403
Mailing Address - Country:US
Mailing Address - Phone:718-648-0705
Mailing Address - Fax:718-836-7912
Practice Address - Street 1:251 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2403
Practice Address - Country:US
Practice Address - Phone:718-648-0705
Practice Address - Fax:718-836-7912
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000087101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health