Basic Information
| Provider Information | |||||||||
| NPI: | 1003095415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10025 W. MARKHAM STREET | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722052178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016634673 | ||||||||
| FaxNumber: | 5018011816 | ||||||||
| Practice Location | |||||||||
| Address1: | 10025 W. MARKHAM STREET | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722052178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016634673 | ||||||||
| FaxNumber: | 5018011816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 99-07P | AR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.