Provider Demographics
NPI:1942254560
Name:CLARK, KENNETH W (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 GRAND TETON PLZ
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1029
Mailing Address - Country:US
Mailing Address - Phone:608-833-9290
Mailing Address - Fax:608-833-9691
Practice Address - Street 1:6510 GRAND TETON PLZ
Practice Address - Street 2:SUITE 406
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1029
Practice Address - Country:US
Practice Address - Phone:608-833-9290
Practice Address - Fax:608-833-9691
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI670-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11676OtherDEAN
WI39012000Medicaid
WI11676OtherDEAN