MEDICARE: ALICE ANN CLARK PHD

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	7094	MA
2	103TC0700X	Clinical Psychologist	048.0057921	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W06Z86	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1598813073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE ANN CLARK PHD

Provider Business Mailing Address
First Line	:	PO BOX 458
Second Line	:
City	:	STOWE
State	:	VT
Zip	:	05672-0458
Country	:	US
Telephone Number	:	802-585-0297
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 S MAIN ST
Second Line	:
City	:	WATERBURY
State	:	VT
Zip	:	05676-1556
Country	:	US
Telephone Number	:	802-585-0297
Fax Number	:

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	12/01/2010

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Directions to “ ALICE ANN CLARK PHD” Practice Location

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