Provider Demographics
NPI:1841284155
Name:CLARK PSYCHOLOGICAL & CONSULTATION PC
Entity type:Organization
Organization Name:CLARK PSYCHOLOGICAL & CONSULTATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:936-639-4993
Mailing Address - Street 1:501 MANTOOTH AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3014
Mailing Address - Country:US
Mailing Address - Phone:936-639-4993
Mailing Address - Fax:936-639-6838
Practice Address - Street 1:501 MANTOOTH AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3014
Practice Address - Country:US
Practice Address - Phone:936-639-4993
Practice Address - Fax:936-639-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22932103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N91JMedicare ID - Type Unspecified