Provider Demographics
NPI:1841206109
Name:CLARK, ALAN E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16951 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3208
Mailing Address - Country:US
Mailing Address - Phone:310-339-8586
Mailing Address - Fax:310-459-5926
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:310-339-8586
Practice Address - Fax:310-459-5926
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12890103TC0700X
CO1436103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12890Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST