Provider Demographics
NPI:1104015155
Name:CLARK, THERESA L (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2098
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-2098
Mailing Address - Country:US
Mailing Address - Phone:970-455-9004
Mailing Address - Fax:949-577-4247
Practice Address - Street 1:114 VILLAGE PLACE
Practice Address - Street 2:ST 207
Practice Address - City:DILLON
Practice Address - State:CO
Practice Address - Zip Code:80435
Practice Address - Country:US
Practice Address - Phone:970-455-9004
Practice Address - Fax:949-577-4247
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1354792084P0800X
FLME1046952084P0800X
FLTRN11797390200000X
CODR.00614132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program