Provider Demographics
NPI:1942758222
Name:CLARK, BRIAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 ROLLING RIVER VW
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-5860
Mailing Address - Country:US
Mailing Address - Phone:210-287-4788
Mailing Address - Fax:
Practice Address - Street 1:2631 BULVERDE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163-2107
Practice Address - Country:US
Practice Address - Phone:210-287-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional