Provider Demographics
NPI:1629008453
Name:CLARK, ROBERT ROY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ROY
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 1:232 ROUTE 80
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1406
Mailing Address - Country:US
Mailing Address - Phone:860-663-2138
Mailing Address - Fax:860-663-2488
Practice Address - Street 1:176 ROUTE 81
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-1422
Practice Address - Country:US
Practice Address - Phone:860-663-2668
Practice Address - Fax:860-663-2488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2170103T00000X
NY4648103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002170CT01Medicare UPIN
NYV50271Medicare ID - Type UnspecifiedPROVIDER NUMBER