Provider Demographics
NPI:1922208339
Name:CLARK, KATHERINE HENDERSON (PSY D)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HENDERSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1655 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3429
Mailing Address - Country:US
Mailing Address - Phone:585-271-2295
Mailing Address - Fax:
Practice Address - Street 1:1655 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3429
Practice Address - Country:US
Practice Address - Phone:585-271-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical