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General NPI Number Information
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NPI Number | 1750826285
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Entity Type | Organization
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Legal Business Name | CONSTANCE AVERY-CLARK, PH.D., LLC
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Dates
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Enumeration Date | 12/19/2016
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Last Update Date | 12/19/2016
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Provider Practice Location Address
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Address Line | 7100 W CAMINO REAL SUITE 302, #7
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City | BOCA RATON
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State | FL
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Zip | 33433-5510
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Country | US
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Telephone | 954-849-7997
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Fax |
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Provider Business Mailing Address
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Address Line | 7100 W CAMINO REAL SUITE 302, #7
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City | BOCA RATON
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State | FL
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Zip | 33433-5510
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CONSTANCE AVERY-CLARK
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Credential | PH.D.
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Telephone | 954-849-7997
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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 | PY3980
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License Number State | FL
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