Provider Demographics
NPI:1720122963
Name:CLARK, PATRICIA R (MS, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 KETTLE POND DR
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-5419
Mailing Address - Country:US
Mailing Address - Phone:401-789-7770
Mailing Address - Fax:401-783-3636
Practice Address - Street 1:186 KETTLE POND DR
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-5419
Practice Address - Country:US
Practice Address - Phone:401-789-7770
Practice Address - Fax:401-783-3636
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI51106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7221-2OtherBLUE CROSS & BLUE SHIELD