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General NPI Number Information
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NPI Number | 1598839755
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Entity Type | Individual
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Provider Name | RICHARD JOSEPH CLARK PSYD
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Gender | Male
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 04/25/2012
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Provider Practice Location Address
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Address Line | 6700 N PORT WASHINGTON RD
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City | GLENDALE
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State | WI
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Zip | 53217-3919
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Country | US
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Telephone | 414-351-0450
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Fax | 414-351-8845
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Provider Business Mailing Address
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Address Line | 2312 N GRANDVIEW BLVD SUITE 104
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City | WAUKESHA
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State | WI
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Zip | 53188-1600
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Country | US
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Telephone | 262-522-8512
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Fax | 262-244-0914
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1893057
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License Number State | WI
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