MEDICARE: DR. IVORY M. ROBERTS-CLARKE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	10446	MA

General Provider Information

NPI Number	:	1134137201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVORY M. ROBERTS-CLARKE PH.D.

Provider Business Mailing Address
First Line	:	500 COLUMBIA RD
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02125-2322
Country	:	US
Telephone Number	:	617-287-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 COLUMBIA RD
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02125-2322
Country	:	US
Telephone Number	:	617-287-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	03/10/2017

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