Provider Demographics
NPI:1942809595
Name:CLARK, LAURA R (SCHOOL PSYCH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:SCHOOL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:NH
Mailing Address - Zip Code:03585-6112
Mailing Address - Country:US
Mailing Address - Phone:603-838-6672
Mailing Address - Fax:
Practice Address - Street 1:25 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:NH
Practice Address - Zip Code:03585-6112
Practice Address - Country:US
Practice Address - Phone:603-838-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH59085103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool