Provider Demographics
NPI:1013120948
Name:CLARK, THERESA S (MSRD,CDE, LD)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSRD,CDE, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NOEL AVE
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1386
Mailing Address - Country:US
Mailing Address - Phone:270-707-0060
Mailing Address - Fax:270-707-0068
Practice Address - Street 1:530 NOEL AVE
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1386
Practice Address - Country:US
Practice Address - Phone:270-707-0060
Practice Address - Fax:270-707-0068
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY38364492OtherTAX ID NO.
KYKY-0517OtherLICENSE DIETITIAN
KY9000505900Medicaid
KYKY-0517OtherLICENSE DIETITIAN