Healthcare Provider Details

I. General information

NPI: 1154235950
Provider Name (Legal Business Name): OLIVIA EMERY CLARK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

IV. Provider business mailing address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

V. Phone/Fax

Practice location:
  • Phone: 267-426-0125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS020859
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: