Provider Demographics
NPI:1023274503
Name:CLARK, WILLIAM DAVE (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DAVE
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 1:1421 OSSAHATCHIE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5339
Mailing Address - Country:US
Mailing Address - Phone:561-319-0625
Mailing Address - Fax:
Practice Address - Street 1:1421 OSSAHATCHIE CREEK RD
Practice Address - Street 2:
Practice Address - City:ELLERSLIE
Practice Address - State:GA
Practice Address - Zip Code:31807-5339
Practice Address - Country:US
Practice Address - Phone:561-319-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC001112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health