Provider Demographics
NPI:1336375328
Name:CLARK, BETTE ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BETTE
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W 79TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6416
Mailing Address - Country:US
Mailing Address - Phone:212-362-6759
Mailing Address - Fax:914-423-3143
Practice Address - Street 1:127 W 79TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6416
Practice Address - Country:US
Practice Address - Phone:212-362-6759
Practice Address - Fax:914-423-3143
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011741-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist