Provider Demographics
NPI:1912000993
Name:CLARK, PATRICIA A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
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 1:1155 LOUISIANA AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2351
Mailing Address - Country:US
Mailing Address - Phone:407-629-4356
Mailing Address - Fax:407-629-1812
Practice Address - Street 1:1155 LOUISIANA AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2351
Practice Address - Country:US
Practice Address - Phone:407-629-4356
Practice Address - Fax:407-629-1812
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5994103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54479Medicare ID - Type Unspecified