Healthcare Provider Details

I. General information

NPI: 1104015155
Provider Name (Legal Business Name): THERESA L CLARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 05/17/2025
Certification Date: 05/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 VILLAGE PLACE ST 207
DILLON CO
80435
US

IV. Provider business mailing address

PO BOX 2098
DILLON CO
80435-2098
US

V. Phone/Fax

Practice location:
  • Phone: 970-455-9004
  • Fax: 949-577-4247
Mailing address:
  • Phone: 970-455-9004
  • Fax: 949-577-4247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN11797
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.135479
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME104695
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0061413
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: