Provider Demographics
NPI:1730458159
Name:CLARK, LAURA KATHLEEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KATHLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E OLIN AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1487
Mailing Address - Country:US
Mailing Address - Phone:608-255-9119
Mailing Address - Fax:608-255-9219
Practice Address - Street 1:122 E OLIN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1487
Practice Address - Country:US
Practice Address - Phone:608-255-9119
Practice Address - Fax:608-255-9219
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2982-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical