Provider Demographics
NPI:1770831901
Name:CLARK, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:2902 JACK PINE ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-5519
Mailing Address - Country:US
Mailing Address - Phone:402-616-5139
Mailing Address - Fax:
Practice Address - Street 1:4611 S 96TH ST STE 222
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1243
Practice Address - Country:US
Practice Address - Phone:402-616-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1825101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health