Healthcare Provider Details

I. General information

NPI: 1629129804
Provider Name (Legal Business Name): BRIAN CLARK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 03/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 RISA RD SUITE A
LAFAYETTE CA
94549-3418
US

IV. Provider business mailing address

PO BOX 290
ORINDA CA
94563-0290
US

V. Phone/Fax

Practice location:
  • Phone: 925-385-8050
  • Fax:
Mailing address:
  • Phone: 925-385-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY25198
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY25198
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY25198
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY25198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: