Provider Demographics
NPI:1215227525
Name:CLARK, CHAD JOSEPH (REHAB SPEC)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:REHAB SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-2617
Mailing Address - Country:US
Mailing Address - Phone:918-313-2436
Mailing Address - Fax:
Practice Address - Street 1:10201 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-2617
Practice Address - Country:US
Practice Address - Phone:918-313-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor