MEDICARE: DR. ELLEN M 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	103T00000X	Psychologist	35SI00132200	NJ
2	103T00000X	Psychologist	009278	NY

General Provider Information

NPI Number	:	1497833321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN M CLARK PH.D

Provider Business Mailing Address
First Line	:	5 PETER COOPER RD
Second Line	:	APT.14 F
City	:	NEW YORK
State	:	NY
Zip	:	10010-6622
Country	:	US
Telephone Number	:	212-228-7363
Fax Number	:	212-473-8211

Provider Business Practice Location Address
First Line	:	2201 BERGENLINE AVE
Second Line	:	2ND FLOOR THERAPEUTIC NURSERY
City	:	UNION CITY
State	:	NJ
Zip	:	07087-3582
Country	:	US
Telephone Number	:	201-558-3735
Fax Number	:	201-392-5048

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/30/2009

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