Healthcare Provider Details

I. General information

NPI: 1700833266
Provider Name (Legal Business Name): THOMAS RANDALL CLARK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 4TH AVE NW
MINOT ND
58703-2967
US

IV. Provider business mailing address

2116 4TH AVE NW
MINOT ND
58703-2967
US

V. Phone/Fax

Practice location:
  • Phone: 701-838-2442
  • Fax: 701-839-1193
Mailing address:
  • Phone: 701-838-2442
  • Fax: 701-839-1193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberND238
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier17462
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier11725
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: