Doctor Name: | GREGORY CLARK |
NPI Number: | 1164409728 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | 2888-125 |
Business Practice Address: | 225 N Beaumont Rd Prairie Du Chien, WI - 538211445 |
Business Phone Number: | 5632522537 |
Business Fax Number: | 6083260420 |
Mailing Address: | 225 N Beaumont Rd, PRAIRIE DU CHIEN |
State: | WI |
Postal Code: | 538211445 |
Phone Number: | 5632522537 |
Fax Number: | 6083260420 |
NPI Enumeration Date: | 12/26/2005 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 2888-125 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |