Provider Demographics
NPI:1851414726
Name:CLARK, CATHERINE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 W BIDDISON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2906
Mailing Address - Country:US
Mailing Address - Phone:817-926-4198
Mailing Address - Fax:
Practice Address - Street 1:3217 W BIDDISON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-2906
Practice Address - Country:US
Practice Address - Phone:817-926-4198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health