Provider Demographics
NPI:1396754370
Name:CLARK, LISA L (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
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:PO BOX 341065
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38184-1065
Mailing Address - Country:US
Mailing Address - Phone:901-385-2342
Mailing Address - Fax:901-382-0140
Practice Address - Street 1:8134 COUNTRY VILLAGE DR
Practice Address - Street 2:#102
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016
Practice Address - Country:US
Practice Address - Phone:901-756-8398
Practice Address - Fax:901-756-8701
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNHSP-1188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3682232Medicaid
TN3682232Medicare ID - Type Unspecified