Provider Demographics
NPI:1700406527
Name:CLARK, KENT WILLIAM
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:WILLIAM
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 1:793 OLD ROUTE 119 HWY NORTH
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-465-5576
Mailing Address - Fax:
Practice Address - Street 1:490 JEFFERS STREET
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-731-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health