MEDICARE: DR. PETER CLARK 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	103TC2200X	Clinical Child & Adolescent Psychologist	571	LA

General Provider Information

NPI Number	:	1447310289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER CLARK PH.D.

Provider Business Mailing Address
First Line	:	203 W 21ST AVE
Second Line	:
City	:	COVINGTON
State	:	LA
Zip	:	70433-3151
Country	:	US
Telephone Number	:	985-867-9333
Fax Number	:	985-892-5057

Provider Business Practice Location Address
First Line	:	203 W 21ST AVE
Second Line	:
City	:	COVINGTON
State	:	LA
Zip	:	70433-3151
Country	:	US
Telephone Number	:	985-867-9333
Fax Number	:	985-892-5057

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. PETER CLARK PH.D.” Practice Location

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