Healthcare Provider Details

I. General information

NPI: 1326405143
Provider Name (Legal Business Name): CLARK PINSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 DEWITT ST
SYRACUSE NY
13203-2801
US

IV. Provider business mailing address

135 DEWITT ST
SYRACUSE NY
13203-2801
US

V. Phone/Fax

Practice location:
  • Phone: 315-514-0401
  • Fax: 315-565-5122
Mailing address:
  • Phone: 315-514-0401
  • Fax: 315-565-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number020187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: