Provider Demographics
NPI:1740304807
Name:CLARK, CYNTHIA ADRIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:ADRIAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W MAIN ST STE 2-W
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2948
Mailing Address - Country:US
Mailing Address - Phone:618-549-1793
Mailing Address - Fax:618-549-1793
Practice Address - Street 1:231 W MAIN ST
Practice Address - Street 2:SUITE 2-W
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2948
Practice Address - Country:US
Practice Address - Phone:618-549-1793
Practice Address - Fax:618-549-1793
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL040796OtherHEALTH ALLIANCE
IL189452OtherHEALTH LINK
IL039-72018OtherBLUE CROSS & BLUE SHIELD
IL189452OtherHEALTH LINK