Provider Demographics
NPI:1306921853
Name:CLARK, MARK L (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 ADA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4985
Mailing Address - Country:US
Mailing Address - Phone:501-932-0352
Mailing Address - Fax:501-932-0354
Practice Address - Street 1:2200 ADA AVE STE 302
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4985
Practice Address - Country:US
Practice Address - Phone:501-932-0352
Practice Address - Fax:501-932-0354
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR89-13P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56270OtherMEDICARE ID