MEDICARE: DR. CORY CLARK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PS01098	RI

General Provider Information

NPI Number	:	1588020051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORY CLARK PH.D.

Provider Business Mailing Address
First Line	:	213 ROBINSON ST
Second Line	:
City	:	WAKEFIELD
State	:	RI
Zip	:	02879-3656
Country	:	US
Telephone Number	:	401-680-9157
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 ROBINSON ST
Second Line	:
City	:	WAKEFIELD
State	:	RI
Zip	:	02879-3656
Country	:	US
Telephone Number	:	401-680-9157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2016
Last Update Date	:	01/13/2016

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Directions to “ DR. CORY CLARK PH.D.” Practice Location

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