Healthcare Provider Details

I. General information

NPI: 1457376238
Provider Name (Legal Business Name): PAUL JEFFREY CLARK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SOUTH 7650 EAST CROW NORTHERN CHEYENNE INDIAN HOSPITAL
CROW AGENCY MT
59022
US

IV. Provider business mailing address

PO BOX 9 CROW N CHEYENNE HOSPITAL BEHAVIORAL HEALTH
CROW AGENCY MT
59022-0009
US

V. Phone/Fax

Practice location:
  • Phone: 406-638-3500
  • Fax: 406-638-3569
Mailing address:
  • Phone: 406-638-3491
  • Fax: 406-638-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1414
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: