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General NPI Number Information
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NPI Number | 1003284274
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Entity Type | Individual
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Provider Name | CLARK ROBERT THOMPSON MA
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Gender | Male
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Dates
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Enumeration Date | 09/04/2015
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Last Update Date | 10/31/2018
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Provider Practice Location Address
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Address Line | 86 W SUNBRIDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1822
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Country | US
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Telephone | 479-435-6360
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Fax |
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Provider Business Mailing Address
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Address Line | 405 CENTRAL AVE
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City | NORTHFIELD
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State | IL
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Zip | 60093-3006
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Country | US
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Telephone | 847-441-5600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1810AP-PL
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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