Provider Demographics
NPI:1508964313
Name:CLARK, DENNIS P (D ED)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:D ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALDWELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801
Mailing Address - Country:US
Mailing Address - Phone:814-371-1100
Mailing Address - Fax:814-375-0120
Practice Address - Street 1:100 CALDWELL DRIVE
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-371-1100
Practice Address - Fax:814-375-0120
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006215L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1300509OtherBCBS