Provider Demographics
NPI:1780004515
Name:PEPPER, CLARK EDWIN
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:EDWIN
Last Name:PEPPER
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 1:1843 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4610
Mailing Address - Country:US
Mailing Address - Phone:918-712-8800
Mailing Address - Fax:
Practice Address - Street 1:1843 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4610
Practice Address - Country:US
Practice Address - Phone:918-712-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor