Provider Demographics
NPI:1700833266
Name:CLARK, THOMAS RANDALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RANDALL
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 1:2116 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2967
Mailing Address - Country:US
Mailing Address - Phone:701-838-2442
Mailing Address - Fax:701-839-1193
Practice Address - Street 1:2116 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2967
Practice Address - Country:US
Practice Address - Phone:701-838-2442
Practice Address - Fax:701-839-1193
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17462Medicaid
ND11725OtherBLUE CROSS BLUE SHIELD
ND17462Medicaid
ND11725Medicare ID - Type Unspecified