Provider Demographics
NPI:1669501136
Name:CLARK, ROGER GALEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GALEN
Last Name:CLARK
Suffix:
Gender:M
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:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:650 JOEL DRIVE
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOEL DR
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5349
Practice Address - Country:US
Practice Address - Phone:270-956-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1187103T00000X
TN2800103T00000X
LA322138103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist