Provider Demographics
NPI:1972716702
Name:CLARK, WILLIAM WALTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTER
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 1:1514 THURBER ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-2565
Mailing Address - Country:US
Mailing Address - Phone:703-904-9046
Mailing Address - Fax:
Practice Address - Street 1:2110 GALLOWS RD # B
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3962
Practice Address - Country:US
Practice Address - Phone:703-506-8378
Practice Address - Fax:703-893-1011
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002215103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical