Provider Demographics
NPI:1154730174
Name:CLARK, ERICA J (PSYD)
Entity type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S HOOVER BLVD
Mailing Address - Street 2:SUITE #165
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3540
Mailing Address - Country:US
Mailing Address - Phone:813-815-0664
Mailing Address - Fax:
Practice Address - Street 1:200 S HOOVER BLVD
Practice Address - Street 2:SUITE #165
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3540
Practice Address - Country:US
Practice Address - Phone:813-815-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical