Provider Demographics
NPI:1780769018
Name:CLARK, R. RAY (PHD)
Entity type:Individual
Prefix:DR
First Name:R. RAY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:R RAY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 8128
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15217-0128
Mailing Address - Country:US
Mailing Address - Phone:412-621-0551
Mailing Address - Fax:412-621-6414
Practice Address - Street 1:5725 FORWARD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-2255
Practice Address - Country:US
Practice Address - Phone:412-621-0551
Practice Address - Fax:412-621-6414
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008392-L103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016409990005Medicaid
PA00180561OtherBCBS
S46121OtherHIGHMARK
PACL951461Medicare UPIN
PA0016409990005Medicaid