Provider Demographics
NPI:1912034596
Name:CLARK, ANDREA RACHELE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:RACHELE
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 1:1818 W LINDSEY ST STE C120
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4169
Mailing Address - Country:US
Mailing Address - Phone:405-801-2400
Mailing Address - Fax:405-701-1185
Practice Address - Street 1:1818 W LINDSEY ST STE C120
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-4169
Practice Address - Country:US
Practice Address - Phone:405-801-2400
Practice Address - Fax:405-701-1185
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200036470-AMedicaid