Basic Information
| Provider Information | |||||||||
| NPI: | 1154806552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | HILARY | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 S EASTERN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672072414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618189394 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4301 WEST MARKHAM | ||||||||
| Address2: | SLOT #589 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015268148 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | 202183 | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.