Healthcare Provider Details

I. General information

NPI: 1841529161
Provider Name (Legal Business Name): HEATHER W CLARK PH.D., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CARRIAGE VIEW DR
WILDWOOD MO
63040-1425
US

IV. Provider business mailing address

104 CARRIAGE VIEW DR
WILDWOOD MO
63040-1425
US

V. Phone/Fax

Practice location:
  • Phone: 314-852-8952
  • Fax:
Mailing address:
  • Phone: 314-852-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006036523
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: