Healthcare Provider Details

I. General information

NPI: 1992053474
Provider Name (Legal Business Name): CHRISTOPHER TAD CLARK M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 DEWAR DR STE 204
ROCK SPRINGS WY
82901-5826
US

IV. Provider business mailing address

4000 DEWAR DR
ROCK SPRINGS WY
82901-6218
US

V. Phone/Fax

Practice location:
  • Phone: 307-630-3466
  • Fax: 307-316-0228
Mailing address:
  • Phone: 307-382-3010
  • Fax: 307-382-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-1198
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1198
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: