Basic Information
| Provider Information | |||||||||
| NPI: | 1841284155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARK PSYCHOLOGICAL & CONSULTATION PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MANTOOTH AVE | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366394993 | ||||||||
| FaxNumber: | 9366396838 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MANTOOTH AVE | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366394993 | ||||||||
| FaxNumber: | 9366396838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9366394993 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.ED. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 22932 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.