Healthcare Provider Details

I. General information

NPI: 1669501136
Provider Name (Legal Business Name): ROGER GALEN CLARK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLANCHFIELD ARMY COMMUNITY HOSPITAL 650 JOEL DR
FORT CAMPBELL KY
42223-5349
US

IV. Provider business mailing address

BLANCHFIELD ARMY COMMUNITY HOSPITAL 650 JOEL DRIVE
FORT CAMPBELL KY
42223-5349
US

V. Phone/Fax

Practice location:
  • Phone: 270-956-0129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1187
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2800
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number322138
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: